Clinical Pharmacology Laboratory - Auburn University

this form

Instructions

Please complete this form.
After clicking "Submit" you will see a confirmation page with a barcode.
Print the barcode and include it in the package with your sample.

Fields marked by an asterisk (*) are required.

*Clinic Information

Please enter the name of your clinic here

Veterinarian Information

Vet First Name	Vet Last Name
*Phone:	Fax:
*Email (your confirmation will be sent to this address):
Notify me by email when this sample is received?

*Report Method:

Fax Email Both

*Recommendations Needed? (No Additional Charge) Yes No

STAT (Additional Charge)

Patient Information

Case/Ref Number:
*Patient (First) Name:	*Owner (Last) Name:
*Species:	Breed:
Sex:	Weight:	kg lb	Age (years):

Presentation Date of Most Recent Relapse:
Primary Diagnosis:

Unknown

Pertinent History (Include secondary diagnoses): characters remaining.

Other Drugs in Use (Excluding any drugs being tested:
characters remaining.

*Abnormal Lab Results?

Monitoring Purpose: Efficacy Toxicity Routine Check
*Clinical Signs Sufficiently Controlled?
Other control comments:

Please choose desired tests and then click 'Continue' for relevant submission information and questions.
Please provide as much information as you can.

For detailed monitoring recommendations, click on a test name.
For information regarding peak and trough sampling, click here.

Tests Requested
Test Name	Single Sample	Peak & Trough (2 samples)
Bromide (Potassium/Sodium)
Cyclosporine
Digoxin
Gabapentin
Leflunomide (Teriflunomide)
Levetiracetam (Keppra®)
Phenobarbital
Theophylline
Zonisamide
Other Test (Full List):

Shipping Labels

A FedEx shipping label for this sample can be created once your sample information has been submitted.

Online Payments

If you received an invoice, you can pay it online at https://aub.ie/clinpharmpay.

Need help? Let us know!

Phone: 334/844-7187
Fax: 334/844-7188
Email: clinpharm@vetmed.auburn.edu

Mailing Address:
Clinical Pharmacology Laboratory
212 Greene Hall
College of Veterinary Medicine
Auburn, AL 36849-5518

Shipping Address:
Clinical Pharmacology Laboratory
1500 Wire Road
Auburn University, AL 36849

GPS Address:
1220 Wire Rd.
Auburn, AL 36832

*Clinic Name
*Address
*City
*State		*Zip code
*Country

Clinical Pharmacology Laboratory Online Submission Form

Please choose desired tests and then click 'Continue' for relevant submission information and questions. Please provide as much information as you can.

*For detailed monitoring recommendations, click on a test name.*For information regarding peak and trough sampling, click here.

Other

Please choose desired tests and then click 'Continue' for relevant submission information and questions.
Please provide as much information as you can.

For detailed monitoring recommendations, click on a test name.
For information regarding peak and trough sampling, click here.