Indian Creek Veterinary Hospital – I-131 Referral Form
Submit I-131 treatment referrals for feline patients to Indian Creek Veterinary Hospital. For use by referring veterinarians only.
Referring Veterinarian Information
Please provide your clinic and contact details.
Referring Veterinarian Name
*
Clinic Name
*
Referring Veterinarian Email
*
example@example.com
Clinic Phone Number
*
Please enter a valid phone number.
Patient Information
Details about the feline patient being referred.
Patient Name
*
Species
*
Please Select
Cat
Breed
*
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Sex
*
Please Select
Male Intact
Male (Neutered)
Female Intact
Female (Spayed)
Hyperthyroidism History
Provide relevant thyroid history for the patient.
Most Recent Total T4 with date
*
Currently on Methimazole?
*
Please Select
Yes
No
Methimazole Dose, Duration, and Tolerance
Diagnostics & Medical History
Indicate diagnostics performed and provide pertinent history.
Diagnostics Performed
CBC / Chemistry
Urinalysis
Blood Pressure
Thyroid Panel
Cardiac Evaluation
Pertinent Medical History / Concurrent Disease
Internal Medicine Review
Internal Medicine consultation is required prior to I-131 treatment.
All I-131 cases are reviewed and managed through the Internal Medicine Service at Indian Creek Veterinary Hospital.
File Upload
Upload recent lab work and medical records.
Upload Recent Lab Work / Medical Records
*
Upload a File
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