Radioiodine Therapy Referral Form
When referring your patient to our hospital, please complete this form along with all pertinent medical records. If this is an emergency which requires treatment within 24 hours, please contact our Emergency Doctor Team directly, 506-387-4015 press option 8. Also, please ensure that you contact the doctor that will be managing the case at Riverview Animal Health Centre to ensure continuity of care.
Referring Veterinarian Information
Name of Referring Veterinarian
*
Name of Referring Hospital
*
Phone Number
*
Email Address
*
example@example.com
Patient Information
Client's Name
*
First Name
Last Name
Client's Email Address
*
example@example.com
Client's Phone Number
*
Patient's Name
*
Breed
*
Age
*
Sex
*
Please Select
Male
Male, Neutered
Female
Female, Spayed
Unknown
Patient History – Include any adverse drug reactions, previous illness, or surgery.
*
Please send medical records, including Radiographs.
Current treatments and response to therapy (attach all pertinent lab results)
*
Please send medical records, including Radiographs.
Any additional comments:
Patient's Medical Records
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preferred Communication
*
I would like a call from the Doctor.
Please book the appointment with the client.
Submit
Should be Empty: