I-131 Therapy Referral Form - Metropolitan Veterinary Associates

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This field is for validation purposes and should be left unchanged.

Referring Hospital Information

Hospital Name*

Veterinarian*

Phone*

Fax

Email*

Client and Patient Information

Client Name*

Client Phone*

Include the best number and any alternate contact numbers

Client Alternate Phone 1

Client Alternate Phone 2

Pet Name*

Age*

Hyperthyroidism Treatment History

Other Thyroid Medication*

Dose*

Include the medication strength and dosing frequency.

Length of Treatment*

Medical History

Cats will remain in isolation for 72 hours and can only receive essential medications during this period.

If yes, please summarize the condition and required treatment*

Include the condition, medication or treatment required, dose, frequency, and any special instructions.

Required Referral Information

Please include the following information with this referral form.

Tests must have been performed within the last 30 days prior to scheduling the iodine therapy appointment. If bloodwork results are pending, they may be sent when available. Please call us with any questions.

CBC, urinalysis, serum chemistry panel, and the original T4/Free T4 results diagnosing hyperthyroidism.
Whole-body lateral and ventrodorsal radiographs. Interpretation is free of charge. Electronic images may be sent by email to i131@metro-vet.com.

Most Current PE Notes

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 512 MB, Max. files: 10.

Upload available CBC, urinalysis, chemistry, and T4/Free T4 results. Pending results may be sent separately when available.

Whole-Body Radiographs

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, dcm, zip, Max. file size: 512 MB, Max. files: 10.

Upload lateral and ventrodorsal radiographs, if available.

Please send all referral information to:

Fax: 610-666-1199
Email: i131@metro-vet.com

For questions, please call 610-666-1050. Thank you for your referral.