Requested Laboratory Testing

Edward Lichten, M.D.,PC
180 East Brown Street
Birmingham, MI 48009 
248.593.9999

OVERVIEW: Laboratory Tests of the endocrine system are able to assist in the diagnosis of core diseases and, must be evaluated prior to any medical intervention for chronic therapy. Be sure to bring your photo ID and this form to the drawing station.  For the closest drawing station to you, call the telephone number listed below.

Lab Reports are to be sent to:

Edward Lichten, M.D., P.C.
180 East Brown Street
Birmingham, MI 48009

Hormonal Assays are processed at:
Quest Diagnostic Laboratories
4444 Gidding Road
Auburn Hills, MI 48326   telephone: 248.373.9120

LABORATORY PROFILE for DIABETES MELLITUS
For those with diabetes defined by an elevated glycogenated hemoglobin (HgB-A1c >6), a FASTING, 3 hour glucose tolerance test (GTT-I) with insulin drawn at 0, 1, 2, and 3 hours is required before treatment. Check the box if DIABETIC.

[___] GTT-I
THREE HOUR GLUCOSE TOLERANCE TEST
1. Fasting Glucose and Fasting Insulin
2. 75 gram Glucola oral glucose load
3. 3-hour Glucose Tolerance Test with  1, 2, and 3 hour insulin

 

FOR ALL future Dr. EDWARD LICHTEN's PATIENTS-
THE FOLLOWING are REQUIRED, INITIAL LAB TESTS

[_X_] LICHTEN LAB PROFILE 
CBC Comprehensive Metabolic Panel
Hepatitis Screen (optional) Lipids -Triglycerides, Chol, HDL
C-reactive protein; Sed Rate Calciferol Vitamin D3 0,25 OH
Cortisol Thyroid Stimulating Hormone
DHEA-S TSH, T3 and T4 free
Estradiol Thyroid antibodies
Testosterone Thyroid peroxidase antibodies
Sex Hormone Bind. Globulin Iron, Iron Binding Capacity
IGF-1 Homocysteine
Insulin fasting Hemoglobin A1c
FSH, LH Progesterone (women-day 23)
Prolactin PSA men only
Pregnenolone RBC magnesium, Zinc, Copper Chromium
 

Signature on file:
 Licensed Physician:       Edward M. Lichten, M.D.
California Physician:
Michigan Physician:
Ohio Physician:

If your state requires laboratory tests to be ordered by a health professional boarded in your State of residence, please have the necessary signature and information completed below:

Dr. Signature:_____________________   Date:__________

State: ______________ Board Number: _______________

Dr. Address: ____________________________________

Dr. City/ State/Zip: ____________________ ___________

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