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Radioactive Iodine Referral form for Cats with Hyperthyroidism

All details to be completed by the referring veterinarian.

Client details

Full Name*

Address*

 

 

Email*

Phone*

Patient's Name*

Age*

Sex*

Desexed*

Breed and Colour*

Agressive*

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Referring Clinic Details

Clinic Name*

Address*

Case Clinician*

Phone*

Email*

Laboratory Results at Original Diagnosis

Urea*

Creatinine*

T4*

Method of T4 testing*

 

 

Urine SG*

Current Hyperthyroid Medications and Dosage

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**We strongly recommend an external laboratory for T4 testing to obtain an actual result as this may affect the dosage of I-131 given.

A blood test measuring the T4, urea and creatinine must be done within 30 days prior to intake for I-131 treatment while the cat is still on hyperthyroid medication.

Laboratory Results 30 Days Pre I-131

Urea*

Creatinine*

T4*

Urine SG*

Treatment, including prescription food, must stop 14 days prior to I-131 treatment. Also stop any fish-flavoured foods. Please note that responsibility for patient suitability is taken by the referring veterinarian. If you have questions or concerns about your patients suitability please contact the treatment supervisor to assist you. Thank you for your referral to Veterinary Care Royal Oak.