Referring Veterinarian Online Form - New Hampshire i-131 at Hopkinton Animal Hospital

Please complete the form below. Required fields are indicated with a red asterisk. Thank you.

Date *

Referring Hospital *

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Hospital Phone

Hospital Fax

Email *

Referring Veterinarian *

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Owner's Name *

Patient's Name *

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Feline Breed *

Age *

Gender *

Any Concurrent Diseases/Problems

Current Treatment/Medications

Additional Comments

Diagnostic Results Required (upload as attachment):

Complete blood count, biochemical profile including BUN, creatinine, ALT, SAP, Na, K and urinalysis (within 60 days of admission)
T4 (or fT4) within 30 days of admission
Lateral and DV (or VD) thoracic radiographs
If the patient is currently on methimazole — and has been for more than 90 days — we require a T4 taken 7 days after cessation of this medication. If you have questions, we can suggest a schedule for stopping, being retested, and arriving for therapy
Please supply all previous T4 values, histories of biopsies, cancer, and any current medical concerns
For peace of mind of our staff, and in accordance with New Hampshire State law, cats need to be current on their Rabies vaccination

Please Attach Blood Work and X-Rays

Click or drag files to this area to upload. You can upload up to 10 files.

NEW HAMPSHIRE i-131