Nutritional Blood Test (NBT) Questionnaire

Please fill out the entire questionnaire completely. Also please send in diagnostics and blood test results from your veterinarian. Upon completion of all information, please call us to confirm that we have received everything.

If you do not feel comfortable sending personal information over the internet, please download the Nutritional Blood Test (NBT) Questionnaire in .pdf format, fill out the form completely and fax to us. If you have questions please contact us.

Visualize Your Animals Wellness
Personal Information
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
E-Mail
Home Phone
Office Phone
Cell Phone
Fax
Patient Information
Animal's Name
Species Canine Feline Horse Bird
  Other (please specify)
Breed
Date of Birth
Sex Male Female
Weight
Spayed/Neutered Yes    Date No
Veterinarian's Name
Veterinarian Hospital
Veterinarian Phone
Veterinarian Fax
Please Indicate Which Service You Are Contacting Us For (Check One)
Nutritional Blood Test (NBT) with Consult $450
Nutritional Blood Test (NBT) without Consult $350
Follow-UP Nutritional Blood Test (NBT) with Consult $350
Follow-UP Nutritional Blood Test (NBT) without Consult $250
Questions About Your Animal
1. What is the specific condition, disease or diagnosis?

2. What specific tests were done to obtain this condition/diagnosis?

3. What is your animal's current diet? (Include any table scraps. home cooked foods and treats)
4. What supplements or remedies is your animal receiving? (Vitamins, Minerals, Homeopathic's, Herbs, Enzymes, Antioxidants, Phytonutrients etc.)
5. Is your animal currently taking any medications? If so, what is the specific name and dosage?
6. Is your animal currently receiving any type of therapy?
(Acupuncture, Medical. Surgical. Chemotherapy, Radiation, Cortisone, etc..)

7. What is your animal's vaccination history? Be specific and include dates when possible.
8. In your opinion, what is your animal's emotional status and history?
9. Please add any additional comments or questions below.

10. How did you hear about us? (Please give person's name if a friend)
11. How would you like to receive your animal's NBT Results?
Mail eMail Fax Pick-up at Earth Animal

Blood work needed for the Nutritional Blood Test (NBT)
CBC, Super Chem, T4 and LDH
WARNING: Speak with your Veterinarian before vaccinating your animal. If your animal suffers from a compromised immune system or are in a fragile state of health, consider the possible side effects. Vaccinate with intelligence. We suggest titer testing.
*A $25.00 fee will be charged to you if 24-hour notice is not given for cancellation of a Phone Consultation.
Refund Policy on Services and Products: All custom formulations are non-refundable. Nutraceutical Support Formulas and Liquid Remedies must be unopened with seal still intact and must be returned within 15 days from the ship date for a full refund.

*NOTE - All supplements and food sold separately.

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