RAI Therapy Referral Form

When referring your patient to our hospital, please complete this form and upload all pertinent medical records.

Hospital Name *

Clinic/Hospital Phone Number *

Clinic/Hospital Fax Number *

Clinic/Hospital Email *

Name of Referring Veterinarian *

Full Name *

Name of secondary contact and/or spouse

Address *

City *

Province *

Postal Code *

Phone Number*

Email Address *

Patient's Name *

Birth Date *

Approximate

Age *

In months/years, or birthdate

Species *

Breed *

Colour / Markings *

Sex *

Weight *

In kg

Other comorbidities (besides hyperthyroidism)

Date of diagnosis *

Medication type & dosage *

Is your patient eating Y/D food? *

Yes
No

Chem 15/CBC/Lytes *

Yes
No

T4 Level (off medications) *

T4 Level measured *

in hospital
in reference lab

Upload Medical Records *

I understand that Petworks Veterinary Hospital has an extensive waitlist and clients will be contacted to arrange a phone consultation approximately a month before when possible treatment will be. *

I understand that if the status of the patient changes after this referral form is submitted, it is my responsibility to update Petworks Veterinary Hospital about any changes and/or to cancel the referral. *

Is the client unsure if treatment is the right fit? Please let us know so we can manage appropriately.

The client is unsure of treatment
The client is fully supportive of treatment
Neutral / I don't know

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

RAI Therapy Referral Form

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

REQUIRED DOCUMENTATION / INFORMATION

RAI Therapy Referral Form

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

REQUIRED DOCUMENTATION / INFORMATION

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