PROGESTERONE TEST ORDER FORM
Fill out information, right mouse click on form, select "Print", then fax to 760.591.9939
TODAY'S DATE
DATE OF BLOOD DRAW
MAILED IN SERUM/PLASMA
TIME OF BLOOD DRAW
OWNER INFORMATION
OWNER
TELEPHONE FAX*
ADDRESS
E-MAIL ADDRESS
CITY/PROVINCE
STATE ZIP COUNTRY
*RESULTS WILL BE FAXED FIRST IF POSSIBLE
BITCH INFORMATION
BITCH NAME
DAY OF SEASON
BREED
DAY OF PREGNANCY
OTHER BREEDING HISTORY
PREVIOUS LITTERS
BREEDING INFORMATION
BREEDING SCHEDULED
LOCAL BITCH TO BE SHIPPED
NATURAL/ AI/ AI IU/ AI SURGICAL
FROZEN/ COOLED SHIPPED IN
TEST RESULT: NANOGRAMS/ML
RECOMMENDATIONS
REPORT TO OWNER/VET FAX
NEXT APPOINTMENT
PERSON REPORTING
DATE TIME
BILLING INFORMATION
MONEY ORDER CHECK VISA/MASTERCARD
EXP. DATE
VVC Code
SEND CHECK OR MONEY ORDER TO: CANINE CRYOBANK, 120 N. PACIFIC A5, SAN MARCOS, CA 92069
DATE SENT