Patient name: _______________________________________ DOB: ______________________` Please read and fill out check list below. This will help us with ordering proper labs for your upcoming appointment. Our standard screening labs include: • Comprehensive metabolic panel is a blood test that measures your sugar (glucose) level, electrolyte and fluid balance, kidney function, and liver function. • Lipid panel is a blood test that measures cholesterol, triglycerides (good) HDL and (bad) LDL • CBC is a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia • TSH test is done to find out if your thyroid gland is functioning properly. • Iron to check iron deficiency and Ferritin is done to check how much iron your body is storing • PSA >50 males: measures a substance produced by the prostate gland. Screening Lab Check List Yes No Addition info. Do you have Medicare? (ABN completed) Are you 50 years or older? Do you have a biometric form that needs to be completed for employer? Are you a diabetic? Are you taking gout medication? Do you take any of the following medication • Tegretol? • Lithium • Carbamazepine • Digoxin • Testosterone If yes please write which medication Would you like to check Vitamin D levels? ( cost can be $200-250 most ins will not cover) Please Note: There may be additional concerns discussed during the Physical Exam that may require additional lab orders. Not all insurance plans cover all lab services. In the event your insurance determines a lab service is “not covered” you will be responsible for the complete charge. I understand and attest the above information is correct to the best of my knowledge. Signature: __________________________________________ Date: _____________________ For office staff- Please check if there are pending ticklers .