Radioactive Iodine Therapy I-131 Patient Referral Form

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5886 Tutt Blvd | Colorado Springs, CO 80923 | 719-473-0482
Radioactive Iodine Therapy I-131
Patient Referral Form
Referring Veterinarian
Patient Information
Referring DVM ________________________________
Owner’s Name ________________________________
Hospital Name ________________________________
Pet’s Name ___________________________________
Street Address ________________________________
Species ________________ Age __________________
City ___________________ State ______ Zip _______
Breed ____________________ Sex: M / NM / F / SF
Phone _________________ Fax__________________
Diagnosis ____________________________________
E-Mail _______________________________________
Previous Medical Conditions _____________________
Preferred Method of Contact: Phone / Fax / E-Mail
_____________________________________________
Date Referral Request Submitted: ___________________________________________________________________
Please send the following information along with this referral:
-
Doctor’s notes and pertinent patient history
-
Lab tests and results, completed and pending (results from the last two weeks preferred)
All labs included _______, Pending labs not included__________________________________________________
Special requests or comments ______________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Thank you for providing prompt and complete records to ensure the best possible care for your patients.
Please let us know if you have any questions.
Contacts: Jules Derrickson, i-131 Lead
Email:
Fax: 719-434-9502
Phone: 719-473-0482

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