Radioiodine New Patient Form

Radioiodine New Patient Form
Please fill out this form and submit electronically by hitting SUBMIT on the bottom of this form. The staff will receive the form in preparation for your upcoming appointment. Your participation will greatly enhance our services. We do appreciate you taking the time to complete each form.
Date

MonthDayYear
Date
Client Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Alternative Phone Number (If Applicable)

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Email*
example@example.com
Owner Drivers License *
Owner Date of Birth *
Cat's Name*
Age of Cat*
Breed of Cat *
Color of Cat*
Sex of Cat*

Male Neutered/ FixedFemale Spayed/ FixedMale IntactFemale Intact
Lifestyle of Cat*

Indoor onlyOutdoor onlyIndoor/Outdoor
Radio iodine (I-131) is a treatment for hyperthyroidism. At admission our attending veterinarian will do a physical examination however, if you have medical concerns other than the hyperthyroidism please address this with your cat’s normal veterinarian. If your cat is an established patient at Cats Veterinary, Dr. Vani and/or Dr. Reagan will have already discussed any concurrent medical concerns.*

I acknowledge the above statement
My cat has the following symptoms (select all the apply)*

MY CAT IS OTHERWISE HEALTHY AND EXHIBITING NO OTHER SIGNS OF ILLNESSIrregular heart rateHeart murmurDifficulty breathingRapid breathing (panting)Diarrhea/ Soft stoolsGI diseaseVomitingDecreased AppetiteIncrease in AppetiteUrinary problems such as stones, crystals or cystitisUrine of Bowel Movements outside of boxDiagnosed kidney diseaseExcessive thirstExcessive urinationFood sensitivity or allergiesHypertension (high blood pressure)Other
If you selected any symptoms above, please describe when the symptom started
List the medications your cat is currently on. Please include name of medication, dose, time of day given: (If none, write "NONE") *
Is your cat currently taking methimazole, tapazole, felimazole or Y/D diet?*

NO- my cat is not on this medication/dietYES, my cat is on this medication/diet
What kind of food/diet does your cat eat?*
Does your cat have any dietary restrictions/known allergies? *
Due to the nature of radioiodine, it is important to know information about the household so the BEST safety precautions can be discussed with you.
Please select ALL that apply*

There is no one under the age of 18 or pregnant that resides in the household.There are persons under the age of 18 or pregnant that reside in the household.There are more than 3 cats that reside in the household.There are dog(s) that reside in the household.
Please provide information about your referring veterinarian:
What is the name of the veterinary facility that diagnosed your cat with hyperthyroidism?*
What is the name of the doctor/veterinarian that diagnosed your cat with hyperthyroidism?*
What is the phone number for the veterinary facility that diagnosed your cat with hyperthyroidism? *

Area CodePhone Number
What is the approximate DATE that your cat was diagnosed with hyperthyroidism?*
Additional Information:
It is necessary that the following diagnostics are performed prior to a radioiodine treatment. Blood work (CBC/ Chem 25 and T4) within 30 days of the treatment (must have been sent to a reference laboratory), an urinalysis, a chest radiographs. These diagnostics should be performed at your normal veterinarian. Our staff will contact your veterinarian at the number listed above to alert them to these additional diagnostics that must be performed.*

I acknowledge the above statement
The radioiodine appointment itself lasts approximately 1 hour. You should bring: your cat in a carrier, enough food for the duration of the stay, any medications your cat may need, radiographs (if unable to email) and one small bedding item (no larger than a bath towel) to place in the cage. Please be aware- any bedding placed in the cage CANNOT be returned to you upon discharge due to federal regulations.*

I acknowledge the above statement
When scheduling the radioiodine appointment, you will be asked if you are interested in additional boarding days. If you are interested in potentially boarding your cat in our nuclear facility for the isolation period this MUST be scheduled when the initial appointment is scheduled. There is limited cages in our nuclear facility. Additional costs do apply to additional boarding days. (choose one)*

I acknowledge the above statement and an NOT interested in additional boarding.I acknowledge the above statement and AM interested in additional boarding. ( Or would like more information about it).
Once your cat is approved for radioiodine treatment, a non-refundable deposit of $775.00 must be paid in order for the I-131 dose to be ordered from the pharmacy. This deposit will be applied to the cost of treatment.*

I acknowledge the above statement
You will need to have the following supplies for your cat upon discharge from the facility (unless additional boarding is reserved): clump-able and flush-able litter, litter box liner(s), latex gloves.*

I acknowledge the above statement
Upon Discharge from the facility, the following restrictions apply to all patients: 1. For 1-2 weeks after discharge, a flush able and scoopable litter must be used in any litter boxes the patient has access to. Caregiver must wear gloves when scooping excrement from the litter box and all excrement must be flushed down the toilet. It is also recommended that litter boxes have a plastic liner. 2. For 2 weeks after discharge, no bleach or oxy products can be used when cleaning up after the patient should they have a urinary/stool accident, vomit or food bowls. This does include any laundry. 3.All cats must be confined to the home premises for the 1-2 week period. If your cat is indoor/outdoor, they must remain inside during this time period.*

I acknowledge the above statement
Cats Veterinary Practice Protocols :
Cats Veterinary utilizes social media as a form of marketing and as an educational resource for pet owners. You may or may not wish to participate as outlined below. Please check the appropriate option.*

I approve the use of my pet in social media posts. ONLY the name of my pet will be ever be shared. No private owner information will EVER be used.I decline the use of my pet in any social media posts.
Financial Policy: Payment Options. Cats Veterinary accepts the following forms of payment: cash, Check via direct deposit, Visa, Mastercard, Discover, American Express. Cats Veterinary also accepts Care Credit and Scratchpay which both require application and approval.*

I acknowledge and agree to the terms of the financial policy: payment options.
Client-Staff Interaction Policy: Our staff has worked tirelessly during COVID-19 to adhere to evolving changes recommended by the CDC and guidelines mandated by the state of Michigan. We do acknowledge that these changes have been frequent, and have caused some inconvenience to our clients. The priority of Dr. Reagan and Dr. Vani is to maintain the safety and health of the veterinary team while still offering high quality veterinary care to our patients and clients. Unfortunately, during COVID-19, the acts of a few are requiring us to establish acceptable guidelines of client-staff interactions. It is expected that all members of our veterinary team will be treated with respect and kindness. This same respect and kindness will be given to each and every owner in return. If we are unable to fulfill your expectations as a veterinary hospital, or if our staff is treated disrespectfully in anyway, we will provide you with your cat(s) medical records and you will be asked to seek veterinary care elsewhere. We do feel all feedback is important and when directed appropriately, can become an opportunity to grow and improve our customer service. If you have concerns regarding your visit or experience at Cats Veterinary please email the office at office@catsvet.com so these concerns can properly be addressed.*

I acknowledge the above statement
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Radioiodine New Patient Form

Due to the nature of radioiodine, it is important to know information about the household so the BEST safety precautions can be discussed with you.

Please provide information about your referring veterinarian:

Additional Information:

Cats Veterinary Practice Protocols :