CCPS# ____________
CLINICAL PATHOLOGY SERVICES SUBMISSON FORM
Comparative Clinical Pathology Services, LLC
Charles E. Wiedmeyer DVM, PhD, DACVP
SHIP SAMPLES TO:
CCPS,LLC
4011 Discovery Drive
N110a
Columbia, MO 65201
Phone: 573-620-4883
SUBMITTER INFORMATION:
NAME ________________________________________
INST/FIRM______________________________________
ADDRESS _______________________________________________
ADDRESS _______________________________________________
______________________________________________
_______________________________________________
CITY _________________ ST_____ ZIP_____________ CITY __________________ ST_____
ZIP_____________
COUNTRY_____________________________________
BILL TO:
NAME ________________________________________
INST/FIRM______________________________________
ADDRESS _______________________________________________
ADDRESS _______________________________________________
______________________________________________
_______________________________________________
CITY _________________ ST_____ ZIP_____________ CITY __________________ ST_____
ZIP_____________
COUNTRY_____________________________________
PO Number: ____________________________________
PHONE #: _____________________________________
FAX #: ________________________________________
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Credit Card: VISA
MasterCard
Discover
Card #: ______________________ EXP: ______/______
E-MAIL: _______________________________________
Case report will be e-mailed to e-mail address provided. If you require a mailed copy, please check here.
SHIPPING DATE _______________________ TOTAL # OF SAMPLES __________
Are you aware of any potential human health hazards, including radioactivity, associated with these sera/blood?
Yes __ No __
If yes, state nature
____________________________________________________________________________________________
Remarks/Study Number/Special Instructions:
____________________________________________________________________________________
_________
____________________________________________________________________________________
_________
Species: ______________________
Sample Description:
□ Plasma from lithium heparin □ Serum (from clotted tube) □ Blood in EDTA or Lithium Heparain (for CBC)
CCPS# ____________
□
Other, please specify _________________________________
SAMPLE ID SAMPLE ID SAMPLE ID SAMPLE ID
1 ________________ 2 ________________ 3 ________________ 4 ________________ 5 ________________ 6
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7 ________________ 8 ________________ 9 ________________ 10 ________________ 11 ________________12
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13 ________________14 ________________15 ________________16 ________________17 ________________18
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19 ________________20 ________________21 ________________22________________23 ________________24
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25 ________________26 ________________27 ________________28________________29 ________________30
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CLINICAL CHEMISTRY:
Volumes of serum/plasma required:
1-4 analytes – 75ul; 4-8 analytes – 100ul;
8-12 analytes – 125ul; >12analytes– 200ul
$5/analyte (1-5 analytes), $4/analyte (6-10 analytes), $3/analyte (>10 analytes)
□ Alanine Transaminase (ALT) □ Albumin (Alb) □ Alkaline Phosphatase (ALP) □ Aspartate aminotransferase (AST)
□ Blood Urea Nitrogen (BUN) □ Calcium (Ca) □ Chloride (Cl) □ Cholesterol (Chol) □ Creatine kinase (CK)
□ Creatinine (Creat) □ Gamma Glutamyl transferase (GGT) □ Glucose (Gluc) □ HDL ($10.00/sample) □ Iron
□ Lactate dehydrogenase (LDH) □ LDL ($10.00/sample) □ Magnesium □ Non-Esterified Fatty Acid (NEFA)
($10.00/sample)
□ Phosphorous (PO ) □ Potassium (K) □ Sodium (Na) □ Total bilirubin (Tbil) □ Total CO2 □ Total Protein (TP)
□ Triglycerides (Trig) □ Urine Creatinine □ Urine Electrolytes □ Urine Protein
4
OTHER: please specify
□ Complete Profile (200ul of serum/plasma ) Glucose, Urea nitrogen (UN), Creatinine, Total Protein, Albumin, Globulins,
Phosphorus, Sodium, Chloride, Potassium, Total CO2, Cholesterol, Triglycerides, Calcium, Total bilirubin, ALP, ALT, GGT
$45.00/ sample, $40.00 (>10 samples)
□ Renal Profile (125ul of serum/plasma) UN, Creatinine, Phosphorus, Sodium, Chloride, Potassium, Albumin, Calcium
$32.00/sample, $29.00sample (>10 samples)
□ Liver Profile (125ul of serum/plasma) Total protein, Albumin, ALP, GGT, ALT, AST, Total bilirubin, Cholesterol
$32.00/ sample, $29.00/sample (>10 samples)
□ Muscle Profile (100ul of serum/plasma) AST, CK, ALT, LDH
$20.00/ sample, $18.00/ sample (>10 samples)
□ Lipid Profile (100ul of serum/plasma) Triglycerides, HDL, LDL, Cholesterol (add NEFA, plus $10/sample)
$30.00/ sample, $28.00/ sample (>10 samples)
Hematology
□ CBC (50ul of whole blood in EDTA or heparin tube) includes red blood cell, white blood cell and platelet parameters
$30.50 / sample, $28.50 (>10 samples)
□ Blood smear review (unstained blood smear for review)
$25.00/sample
□ Bone marrow cytology (unstained bone marrow smear, does not include a cell differential)
$45.00/sample
□ Reticulocyte Count
$10.00/sample
CCPS# ____________
Cytology
□ Cytologic exam
$38.00/sample
□ Fluid analysis (Submit fluid in EDTA tube)
includes total nucleated cell count, total protein, specific gravity and cytologic
interpretation)
$43.00/sample
Urinalysis
□ Urinalysis (includes dipstick, sediment exam)
$18.00/sample
□ Urine electrolytes, creatinine or protein
$ 5.00/analyte
Coagulation Profile
□ Prothrombin Time (PT) and Partial thromboplastin time (PTT)
$32.50/sample
Contact Information
Any Questions?
Please Contact:
Charles E. Wiedmeyer
573-620-4883
compclinpath@gmail.com