Radioactive Iodine Therapy Referral Form

Radioactive Iodine Therapy Referral Form

Please fill out this form with as much detail as possible.
Referral Hospital Information:

Referring VeterinarianHospital Name
Contact Information:

Referring Veterinarian/Hospital Email:Referring Veterinarian/Hospital Phone:
Pet Owner Information:

Owner's First Name:Last Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Cat's name
Cat's breed
Cat's sex:

Female, SpayedMale, NeuteredMaleFemale
Cat's age/DOB
Pertinent Medical History (other than thyroid disease): Please note, only clinically stable cats are accepted for treatment. If there is evidence of uncontrolled concurrent illness, the patient will not be eligible for treatment until deemed stable. Please have the owner continue methimazole unless there is concern for adverse event/reaction.
Clinical Data at Diagnosis of Hyperthyroidism:
Date:
Weight:
Total T4:
Appetite:
Other clinical signs reported:
BUN:
Creatinine:
SDMA:
TSH (if performed):
Urine Specific Gravity:
Please note: If a patient is referred without the requested pre-requisite lab data, pretreatment studies can be performed on-site for an additional charge.
Clinical Data After Methimazole Trial:
Date:
Weight:
Total T4:
Current Methimazole Dose:
Length of time on Current Dose:
Route of Administration:

OralTransdermal
Current Appetite:
Other Clinical Signs Reported:
BUN:
Creatinine:
SDMA:
TSH (if performed):
Urine Specific Gravity:
Veterinarian or Hospital Representative's Signature:

Clear
Thank you for your referral! We will send a copy of records and treatment at the conclusion of your patient's visit with us.
Should be Empty:

Radioactive Iodine Therapy Referral Form

Clinical Data at Diagnosis of Hyperthyroidism:

Clinical Data After Methimazole Trial:

Thank you for your referral! We will send a copy of records and treatment at the conclusion of your patient's visit with us.