Please print this form, fill it out and mail or fax
to:
Evergreen Equikits, Inc.
P O Box 680271
Franklin, TN
37068-0271
fax: 615-790-6976
| Name:_________________________________________ | Phone: __________________ |
| Shipping Address:__________________________________ | Fax: ________________ |
| City: ________________________ State _____ZIP _________ | email: _______________________ |
| Name(s) of Horse(s) to be tested (if known): ___________________________________ | |
| Payment Method: (circle one) Check or Money Order (enclose with order) | |
| Credit Card (circle) MasterCard Visa Discover American Express | |
| Card Number: ________________________ Expiration Date: ___________ | |
| ZIP Code of card billing address (if different from above) ____________ | |
Indicate the tests and quantities you wish to order:
| QTY. | COST | TEST | ||||
| ____ | $28.00 | PROGESTERONE | ||||
| ____ | $28.00 | TOTAL ESTROGENS | ||||
| ____ | $28.00 | TESTOSTERONE | ||||
| ____ | $23.00 | T3 | ||||
| ____ | $23.00 | T4 | ||||
| ____ | $28.00 | INSULIN | ||||
| ____ | $28.00 | CORTISOL | ||||
| ____ | $38.00 | PROGESTERONE + TOTAL ESTROGEN | ||||
| ____ | $38.00 | PROGESTERONE + T4 | ||||
| ____ | $54.00 | PROGESTERONE + PMSG | ||||
| ____ | $44.00 | COMBINATION OF 3 TESTS ABOVE SAME ANIMAL |
||||
| ____ | $44.00 | ACTH | ||||
| ____ | $44.00 | LH | ||||
| ____ | $44.00 | FSH | ||||
| ____ | $38.00 | PMSG | ||||
| ____ | $96.00 | STALLION PANEL FSH, T4, TESTOSTERONE, TOTAL ESTROGEN, INSULIN |
||||
| ____ | $105.00 | hCG STIMULATION TEST (MARE) | ||||
| ____ | $98.00 | hCG STIMULATION TEST (STALLION) | ||||
| ____ | $61.00 | TESTOSTERONE ONLY | ||||
| ____ | $93.00 | CUSHINGS SCREEN T4, INSULIN, CORTISOL |