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CATT - Vet Clinic Referral Form
Please submit the information below to refer a patient for Tc-99 scintigraphy and/or I-131 Hyperthyroidism treatment.
Nearest Treatment Location
*
Please Select
Round Rock (ATX), Texas
Spring (HTX), Texas
Sandy (SLC), Utah
Clinic Name
*
Phone Number
*
Doctor's First Name
*
Doctor's Last Name
*
Doctor's Email
*
Pet owner's first name
*
Pet owner's last name
*
Pet owner's email
*
Pet owner's phone
*
Patient Name
*
Patient Age
*
Breed
*
Weight (kgs)
Patient Sex
*
Please Select
Female - Intact
Female - Spayed
Male - Intact
Male - Neutered
Temperament
Please Select
Extreme caution - aggressive or very likely to bite
Caution - might bite during procedures
Normal precautions - average temperament
Patient is a complete and total love bug
Other
Clinical signs?
*
Does the patient have a heart murmur?
*
Please Select
Yes
No
Unsure
Can we sedate this patient if necessary?
*
Please Select
Yes
No
Call to discuss
Date of most recent Thyroid levels?
Month
/
Day
/
Year
BUN / Creatinine / USG?
Administering Methimazole?
*
T4 Level on Methimazole?
Coexisting Diseases?
Medical records and lab results
Please upload medical records, lab results and radiographs (if available) below, or email to
info@catt.vet
Attach Here
Submit