Referral Form

Hyperthyroid Cats Radiotherapy

Referring Veterinarian / Client / Patient
Name / Name
Clinic / Birth
Date
Mailing
Address / Breed
City / Colour
Postal Code / Weight
Phone / Sex /
  • Neutered Male
  • Male
  • Spayed Female
  • Female
[You can affix the patient’s label here]
Cell
Fax
Email
Vaccine History – Date and Type: [Note that because of the hospital stay of 7-10 days, it is recommended that vaccination for upper respiratory diseases have taken place within the last 12 months]
Pretreatment (if being treated with methimazole)
  • T4 ______nmol/l on (date) ______
  • Highest recorded T4 ______nmol/l on (date ______

Any recorded weight data from last 12 months:
Current therapy for hyperthyroidism and date started:
Thyroid nodule(s) palpable and size:
Right: ______Left ______
Other required data: /
  • Heart Rate ______
  • Gallop ______
  • Murmur ______
  • Tachypnea ______
  • Polyuria? ______
  • Polydypsia? ______
/ Please comment on your patient’s temperament:
  • Friendly
  • Shy
  • Fearful

Appetite - Note that owners of patients with special dietary needs should be advised to supply the diet at the time of treatment. /
  • Voracious
  • Good
  • Fair
  • Picky

REQUIRED within one month prior to therapy – Please scan/email or fax this information.
CBC. Chemistry panel, T4 (from reference lab, not bench top testing), urinalysis. Note that T4 results from other than reference labs tend to be semi-quantitative and occasionally inaccurate and therefore cannot be used to calculate I-131 doses. We recommend Idexx/Vitatech or AVC reference labs. Treatment with methimazole is not required prior to RAI treatment and is preferable in most cases.
Once your referral is received, a consult will be scheduled to review treatment options and outcomes. Consult appointments take approximately one hour. Pet owners have many concerns and questions and often feel considerably more comfortable about their cat’s condition and treatment protocols afterwards. The cost of this consultation is applied to the cost of treatment if the client decides to pursue R.A.I. therapy. The cure rate is 95% with a single injection. Patients are treated in groups once monthly. Patients must stay in the R.A.I. facility for 7-10 days after treatment.
Referring Veterinarian Signature:
(Electronic if completed on-line or signed if scanned/faxed)

If you have any questions about referring a patient for rehabilitation, please don’t hesitate to contact us.

Thank you – Rick Swinemar, DVM

Contact information [Please scan/email information wherever possible]:

PetFocus – Petworks Veterinary Hospital

850 Portland Street, Dartmouth, NS, B2W 2N3

Tel: 902-435-2444 ext 1. Fax: 902-462-5285

Email: