Cannabinoid Therapy Submission Form Submit patient and product sample and product label to:Clinical Pharmacology Laboratory, 1500 Wire Road, 214 SRRC, Auburn University, AL 36849. Results will be reported through the Therapeutic Drug Monitoring Laboratory. Email: clinpharm@auburn.edu Call (334) 844-7187 with questions or concerns Your Email Address* Enter Email Confirm Email Patient InformationPatient name* Owner Last Name* Species* Breed* Sex* Age* Weight* kg or lbVeterinarian* Veterinarian Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Veterinarian Phone*Veterinarian FaxVeterinarian Email* Enter Email Confirm Email TreatmentPrimary disease/reason for treatment* Concurrent illnesses* Other medications patient is receiving* Drug* Dosing regimen* Duration* Analgesia* Rank the patient response to relevant clinical signs: (0 = no response, 10 = resolution of clinical signs)Analgesia* Rank the patient response to relevant clinical signs: (0 = no response, 10 = resolution of clinical signs)Seizures* Rank the patient response to relevant clinical signs: (0 = no response, 10 = resolution of clinical signs)Vomiting* Rank the patient response to relevant clinical signs: (0 = no response, 10 = resolution of clinical signs)Inappetence* Rank the patient response to relevant clinical signs: (0 = no response, 10 = resolution of clinical signs)Lameness* Rank the patient response to relevant clinical signs: (0 = no response, 10 = resolution of clinical signs)Quality of life* Rank the patient response to relevant clinical signs: (0 = no response, 10 = resolution of clinical signs)Other (Please Describe)Adverse EventsAtaxia* Please indicate and evaluate severity (1 = mild, 5 = severe) of adverse events as they relate to the patient.Mentation* Please indicate and evaluate severity (1 = mild, 5 = severe) of adverse events as they relate to the patient.Behavioral* Please indicate and evaluate severity (1 = mild, 5 = severe) of adverse events as they relate to the patient.GI* Please indicate and evaluate severity (1 = mild, 5 = severe) of adverse events as they relate to the patient.Cardiovascular* Please indicate and evaluate severity (1 = mild, 5 = severe) of adverse events as they relate to the patient.Respiratory* Please indicate and evaluate severity (1 = mild, 5 = severe) of adverse events as they relate to the patient.Describe adverse eventOther (List and score adverse event)* Product and Dosing InformationProduct Name* Manufacturer* Product Type* Oil Capsule Tablet Biscuit Plant Route of administration* Oral (Swallow) Oral (transmucosal) Inhalant Biscuit Topical CBD* Labeled cannabinoid concentration (mg per ml, tablet, biscuit, etc)THC* Labeled cannabinoid concentration (mg per ml, tablet, biscuit, etc)Not Known* Other product ingredients (list)Dose (total mg or # ml, capsules, cookie per dose)* Days at current dose* Time of last dose : Hour Minuet AM PM Sample collection time(s): (1)* : Hours Minutes AM PM Sample collection time(s): (2)* : Hours Minutes AM PM Describe the product sample sent (eg, capsule, biscuit, ml)*Please attach image of labelMax. file size: 49 MB.An image or the entire label is importantCaptcha
