I-131 Referral Form

    Referring Veterinarian Information

    How would you prefer to be contacted about this case?PhoneFaxEmail

    Client Information

    Patient Information

    SPECIES: Avian/ExoticCatDogOther

    SEX: FFSMMNUnknown

    What is needed prior to treatment:
    1. CBC, chemistry panel and urinalysis at least one month prior to treatment.
    2. Complete medical record from the time of diagnosis of hyperthyroidism, including pretreatment T4 value.
    3. If the patient is on methimazole (Tapazole or Felimazole) or other anti-thyroid medications, the owners should stop giving medications at least 5-7 days prior to the time of treatment.
    4. If a heart murmur, arrhythmia, tachycardia or signs of respiratory disease are present, a chest x-ray and/or echocardiogram are required.
    5. We may repeat a serum T4 level on or close to the day of treatment.

    Does the patient have any concurrent underlying medical condition(s)?

    Has the patient been treated with methimazole (Tapazole or Felimazole)?YesNo
    If yes:

    Any adverse reactions to the drug?
    Has blood work been rechecked since starting the drug?YesNo

    Has the patient been treated with Hill’s Y/D prescription diet?YesNo

    Is the patient on any other medications? If so, doses?

    Past pertinent history?

    Please Note

    Dr. Harley can work with you to help perform any of the necessary pre-treatment work up (if you prefer) and can help answer any additional questions about referral or treatment.

    Cases will always be referred back to you once the cat has been evaluated and treated at Central, although it is recommended that cats return to our facility for any medical issues that develop during the radioactive period (first 3 weeks after release).

    Please attach any documents or images related to this case below.
    You may also fax any information to 203-867-5195