Blood Test Request – TDL Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient TitleMrsMsMissMrDr.Prof.SirOtherForename *Surname *Gender *FemaleMalePatient Clinic ID *Blood Tests (Combined Sets)Female Infertility Profile (FSH, LH, PROL, OEST) [FIP]HRT Profile 1 (FSH, OEST, PROG) [HRT]EQU1 – Equilibrium Menopause Profile (DHEA, OEST, PROG, TEST, VITD, B12)EQU4 – Equilibrium Menopause Review (DHEA, TEST, PROG, OEST)EQU2 – Equilibrium Peri-Menopause Profile (DHEA, OEST, PROG, TEST, FSH, VITD, B12)Thyroid (Basic) (TSH, FT3, FT4) [TF3]Thyroid Profile 1 (TSH, FT4) [TF]Thyroid Profile 2 (FT3, FT4, T4, TSH, TGA, TPEX) [TF2]Complex Prostate Specific Antigen (PSA) [CPSA]Prostate Profile PF2 (Total & free PSA) [PF2]Andropause Profile (DHEA, FSH, TEST, LH, SHBG, Free Androgen Index) [ANDP]Blood Tests **DO NOT SELECT PROGESTERONE FROM THIS LIST IF DAY 21 IS REQUIRED**1 25 Dihydroxy VitD [D3]Albumin [ALB]C Reactive Protein [CRP]Cholesterol [CHO]Cortisol [CORT]Dihydrotestosterone [DHT]D.H.E.A. Sulphate [DHEA]Erythrocyte Sediment Rate [ESR]Ferritin [FERR]Free T3 [FT3]Free T4 [FT4]FSH [FSH]Full Blood Count [FBC]Haemoglobin [HB]HbA1c [GHB]Hepatitis B Immunity [HBIM]Immunoglobulin G [IGG]Immunoglobulin M [IGM]Insulin [INSU]Iron [FE]Lipid Profile [LIPP]Liver Functions Tests [LFT]Luteinising Hormone [LH]Oestradiol [OEST]Oestrone [E1]Pregnenolone [PREN]Progesterone [PROG]Prolactin [PROL]Random Blood Glucose [RBG]Reverse T3 [RT3]Sex Hormone Binding Globulin [SHBG]Testosterone – Free [FTES]Testosterone – Total [TEST]Thyroglobulin Assay [TGA]Thyroid Antibodies [THAB]Thyroid Peroxidase AB [TPEX]Thyroxine [T4]Total PSA [PSPA]Toxoplasma Igc & Igm abs [TFAM]Triiodothyronine [T3]TSH [TSH]TSH Receptor Antibodies [TSI]Vitamin B12 (Active) [B12]Vitamin D [VITD]Zinc [ZINC]Any additional notes for the Lab?Are these first time or Review bloods? *These are first time bloodsThese are pre-review bloodsPlease mention below if the patient should avoid any meds before providing a blood sample or take any other steps:Are additional blood, saliva or breath tests required?Day 21 Progesterone (complete LMP box below)Salivary Cortisol Test RequiredSalivary Cortisol + CAR Test RequiredDutch Complete Test Required! (Urine) [HOR30]Dutch Plus (Saliva/Urine, with CAR) Test Required [HOR43]Menopause Plus (Saliva/Urine) Test RequiredSIBO (Small Intestinal Bacterial Overgrowth) Test RequiredNutrEval FMVGI Effects – StoolMenopause Plus includes oestradiol, progesterone, testosterone, oestrogen metabolites, cortisol, DHEA, and melatonin. Use Notes box below for any specific instructions or Day 21 info.LMP (if known & Day 21 required)Any additional notes for Equilibrium Team and/or Details of Additional Blood/Saliva TestsPhoneSubmit
