Home
FAQ
Office Location
Client Feedback
Contact Us
Referral
Other Resources
Feline Thyroid Clinic

Feline Thyroid Clinic 131I Treatment Request Form

This form be filled out and submitted by referring DVM only.

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

2. After referral form is submitted, have client call the clinic to schedule treatment.

NOTE: DATA FIELDS MARKED WITH AN ASTERISK ARE REQUIRED

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



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 T4 at initial diagnosis -
Total T4*:
Date (e.g. 02/15/2019)*:
 
Total T4 (within 90 days of treatment, off methimazole at least 7 days) -
Total T4 (see above line): Must be a reference lab value, not in-house T4. If T4 is >24 ug/dl, call before submitting
Date (e.g. 02/15/2019): *not required if initial diagnosis less than 90 days ago.
 
Methimazole administered?* Yes No
Start Date (e.g. 02/15/2019):
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:
 
If IRIS Stage 2-4 renal insufficiency is present (urine specific gravity less than 1.030 and/or significant azotemia or SDMA elevation), then a methimazole trial should be recommended prior to referral for 131I treatment. If the owners have been advised of the risk of worsening renal function post 131I treatment and still want to pursue 131I anyway, these patients can be considered for treatment.
 
 
Owner has declined methimazole trial and is aware of risks.*
 
 
 

1045 Gateway Lp, Suite F • Springfield, OR 97477
Phone/Fax: 541.744.2966 • Office Hours By Appointment Only
©2019 Feline Thyroid Clinic. All Rights Reserved.

Home FAQ Office Location Client Feedback Referral Info Other Resources Contact Us