Feline Thyroid Clinic

131I Treatment Request Form - Feline Thyroid Clinic

To be filled out and submitted by referring DVM

IMPORTANT: Click here to read the 131I Treatment Referral
Information page BEFORE submitting this form.

NOTE: 131I treatment request form can be submitted to the Feline Thyroid Clinic via two methods:

1. Fill out this web form and submit via the web.
- OR -



NOTE: DATA FIELDS MARKED WITH AN ASTERISK ARE REQUIRED

DVM INFO:
 
Referring Hospital*:
Veterinarian Name*:
Phone*:
Fax*:
Email*:
 
 
CAT OWNER INFO:
 
Owner Name*:
Owner Home Phone*:
Owner Cell Phone*:
 
 
CAT INFO/DATA:
 
Cat Name*:
Age*: years
Sex: M F Mc Fs
Breed:
 
Weight:
Current Weight (lbs.)*:
Original or Euthyroid Weight (lbs.)*:
 
Total and/or free T4 at initial diagnosis:
Total T4*:
Free T4:
Date (e.g. 02/15/2012)*:
 
Highest Total T4*: (specific value is required; > values are not acceptable)
Date (e.g. 02/15/2012)*:
 
 
ADEQUATE RENAL FUNCTION:**
 
Methimazole or Y/D trial performed?* Yes No
Date of euthyroid blood draw (e.g. 02/15/2012):
T4:
BUN:
CRE:
 
Urine Specific Gravity*: (if > 1.035, methimazole trial not required)
Date (e.g. 02/15/2012)*:
 
Methimazole administered?* Yes No
Start Date (e.g. 02/15/2012):
Current Daily Dose:
Side Effects? Yes No
If yes, please describe:
 
Palpable Thyroid Mass?* Yes No
Diameter > 2cm?* Yes No
 
Abnormal findings on auscultation, abdominal palpation,
radiographs or ultrasound?*
Yes No
If yes, please summarize:
 
Intercurrent health problems or medications
other than methimazole?*
Yes No
If yes, please summarize:
 
** Urine specific gravity of 1.035 or higher, and/or a methimazole or Y/D trial with stable euthyroid BUN/CRE strongly support that cats will have adequate renal function after 131I therapy. Not all cats can tolerate methimazole, or be medicated, or have owners who want to complete a methimazole or Y/D trial. If the owners have been appraised of the risks of possible post-131I renal function decline and want to pursue 131I anyway, these patients will be considered for treatment.
   
Owner has declined methimazole or Y/D trial and is aware of risks.
   
(NOTE: If neither a methimazole nor a Y/D trial has been done, and/or if urine specific gravity is less than 1.035, then by checking this box and submitting this form, the referring DVM certifies that the cat owner has been made aware of the risks).
 


1045 Gateway Lp, Suite F • Springfield, OR 97477
Phone/Fax: 541.744.2966 • Office Hours By Appointment Only
drdoug@felinethyroidclinic.com
www.felinethyroidclinic.com

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