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Referral Form

 








Services Requested: (please check all that may apply)

VETERINARIAN INFORMATION



PATIENT INFORMATION



HISTORY

Patient History and Primary Concern for Transfer
Diagnostics


Treatment and Medication

Radioactive Iodine Referrals

Date of Initial Diagnosis
Highest T4 Documented
Responses to Tapazole if initiated:

Please attach: CBC w/ differential, complete biochemical profile, thyroid results, urinalysis with sediment, retrovirius testing for FELV and FIV and send two view thoracic and abdominal radiographs