Veterinary Referrals

Patient Medical Record Request Form

Click here to print and fax the form. Information may be sent by mail, fax, prepaid FedEx mailer or through this web page.

Veterinarian Information:

Name:
Hospital:
Address:
Telephone:
Fax:

Patient Information:

Client name:
Address:
Telephone:
Patient name:
Age:  yrs    Breed: 
Sex:  M   MN   F   FS

Your input is very vital in the final decision to proceed with therapy. If the provided information indicates health-related problems that may preclude or complicate therapy, you, the referring veterinarian will be contacted to discuss these issues.

The following information is requested to aid in planning I-131 treatment for this patient. Please include any additional information that you feel may be relevant for the pre-treatment assessment of this patient.

Medical History:

1. Evidence of renal disease/failure? Yes     No 
2. Evidence of heart disease/failure? Yes     No 
3. Other medical problems:
4. Does the cat have a chronic history of any of the following disorders:
(If yes, please explain below)
Upper Respiratory Urinary Tract Disorders
Asthma/Pulmonary Disease Chronic Renal Failure
Gastrointestinal Disease Other Endocrinopathy
Explanation:
5. Other chronic problems of concern:

Previous Treatment for Hyperthyroidism:

1. Previous Treatment: Methimazole    Previous I-131
Other:
2. Has The Cat Received Methimazole? Yes     No 
3. Was euthyroidism achieved while the cat was receiving methimazole? Yes     No 
4. Renal function while the cat was euthyroid:
Date
Bun
Creatinine
Urine Specific Gravity
T4
Other
Not Assessed
5. Evidence of adverse drug reaction? Yes     No 

During treatment and isolation:

1. Medication required during treatment period? Yes     No 
2. Is the cat in good overall health and in stable condition? Yes     No 
Additional Information
  

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