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 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*OilCapsuleTabletBiscuitPlantRoute of administration*Oral (Swallow)Oral (transmucosal)InhalantBiscuitTopicalCBD*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)* : HH MM AM PM Sample collection time(s): (2)* : HH MM AM PM Describe the product sample sent (eg, capsule, biscuit, ml)*Please attach image of labelAn image or the entire label is importantCaptcha
