Radioiodine (I-131) Referral Form - Animal Emergency & Specialty Center
ADVERTISEMENT
110213 Kingston Pike
Knoxville, TN 37922
p: 865.693.4440 | f: 865.690.6109
RADIOIODINE (I-131) REFERRAL FORM
rDVM INFO
Referring Clinic:
Date:
Referring Vet:
Vet Phone:
Vet Fax:
Preferred Contact: □
□
□
Vet Email:
PHONE
EMAIL
OTHER:
CLIENT INFO
Owner Name:
Owner Email:
Owner Address:
City:
State:
ZIP:
Owner Phone:
Cell Phone:
Other Phone:
PATIENT INFO
Patient Name:
Patient DOB/Age:
Weight:
Patient Breed:
Patient Gender:
Spayed/Neutered?
M F
Y N
Vaccination Status:
Date of Initial Diagnosis:
Initial T4:
Current T4:
Current Therapy for Hyperthyroidism:
Dose/Route:
***Methimazole should be discontinued three (3) days prior to the I-131 treatment date
□
□
□
□
Size of Thyroid Nodule:
NONE
SMALL (<5 mm)
MEDIUM (5-10 mm)
LARGE (>10 mm)
Current CBC/Chem/Urinalysis
:
Thoracic Radiographs
:
(PLEASE SEND/EMAIL)
Y N
(PLEASE SEND/EMAIL)
Y N
Other Medical Problems:
Current Medications
:
(PLEASE INCLUDE DOSAGE, DURATION, & SCHEDULE)
Is Sedation Necessary with This Patient?
Y N
LAB WORK
The following laboratory tests are required within one (1) month of appointment:
CBC CHEM PANEL T4 URINALYSIS
Please send the results of these labs as well as labs at the time of initial diagnosis.
***If cardiac disease is suspected, an echocardiogram is also recommended
Please fill out this form completely and send with patient records, lab work, and radiographs to…
|
865.690.6109
EMAIL:
FAX:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical