Radioiodine History/Admission Form

Radioiodine History/Admission Form/ CATS Facility Consent

Cats Veterinary * 43727 Gratiot * Clinton Twp, MI 48036 * 586-463-9550
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
Cat's Name*
My cat is currently exhibiting the following symptoms:

Decreased AppetiteIncreased AppetiteVomitingDiarrheaConstipation/ Infrequent bowel movementsCoughingSneezingEye DrainageOther
If you selected any of the above symptoms: please describe when the symptoms started and how often they occur:
Medications or Supplements:*

My cat is NOT on any medications or supplements.My cat IS on medications/supplements. Make sure to detail all medications/supplements below.
Medications or Supplements: IF your cat is on medications or supplements, list the medication, dose, frequency given and time of day given below.
Medications/ Supplements:
You must bring enough medications/ supplements to be given to your cat during the hospitalization.*

I acknowledge the above statement.I acknowledge the above statement, my cat is NOT on any medications/ supplements.
Please describe the brand/kind of food you feed your cat. If your cat has any dietary restrictions make sure to include details below. Please include how much you feed your cat at each meal. During hospitalization for radio iodine, your cat will be offered fresh food and water twice a day. *
You must bring enough food/treats for your cat for the duration of the stay. We encourage extra cans/ portions of food be supplied as we will entice your cat with fresh food offerings throughout the day. IF you do not supply enough food for your cat, your cat will be offered food out of our hospital stock. We carry OTC friskies canned ( flavor varies) and proplan dry.*

I acknowledge the above statement
You are permitted to bring one personal item (bedding or toy) for your cat to be placed in the housing unit. The item must not be larger than a towel. Any item placed into the housing unit cannot be returned after treatment due to federal regulations. If you choose not to bring an item from home, your cat will be given comfortable bedding from our hospital supply.*

I acknowledge the above statement.
I understand that radioactive iodine has 95% cure rate. In the instance that my cat was to be within the 3-5% failure rate of treatment percentage and subsequent treatment were to be recommended, I would be financially responsible for re-treatment.*

I acknowledge the above statement.
Upon admittance to the facility, your cat will be given an anti-nausea medication. If your cat were to vomit after the administration of radioiodine, an additional dose will be promptly ordered and administered to your cat at no additional cost. The re-administration of radioactive iodine may result in an additional day of hospitalization. There will be no additional cost of required hospitalization, however, if additional days are needed beyond the federally mandated regulation, additional charges will apply.*

I acknowledge the above statement.
Your cat will be closely monitored for any signs of illness during the hospitalization. The most common hospitalized clinical symptom is GI upset. This is NOT a symptom of radioactive iodine itself, but in most cases a stress response. If the attending doctor needs to prescribe medication to treat any illness, I wish (select one)*

To be contacted to approve any additional services. I understand that in the event I cannot be contacted for consent, this may delay the start of treatment.I consent for 5% of treatment cost (approximately $100.00) in additional services. Beyond that amount I request to be contacted with an estimate.
Follow up care after treatment is recommended in one month, three months and six months. For best care, it is recommended to have the follow-up appointments and recheck blood work performed at this facility. All other unrelated care will be referred to your normal veterinarian. The cost of a follow up appointment is NOT included in the initial treatment. An estimate for follow-up appointments will be provided at discharge. If you do choose to have follow up appointments performed at your normal veterinary office, it is requested that results be reported to the treating facility.*

I acknowledge the above statement.
Appointment Reminders:
- Please do not feed your cat 1 hour prior to travel. This will help futher decrease any nausea prior to the administration of the oral I-131 pill. At adimission, your cat will also be given an anti-nausea medication.
- If your veterinary clinic does not have digital radiographs that have already been sent, please bring in the radiographs for review.
- Those adults caring for the cat while in isolation should attend the consultation with the doctor. The treatment and saftey requirements will be discussed at this time.
- You are welcome to call anytime during normal business hours for updates on your cat. The staff will call the phone number on file if there are any health concerns that arise during hospitilization. Visitation is strictly prohibited due to NRC radiation saftey requirements.
- Full payment is due at admission to the facility.
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Radioiodine History/Admission Form/ CATS Facility Consent