Referral Form Referring veterinarian information: Veterinary Hospital Name * Doctor's Name * First Name Last Name Suffix/Degree DVM VMD BSVM Other (Fill below) Email * Phone (###) ### #### Clinic Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Client Information: Name * First Name Last Name Email * Phone (###) ### #### Patient Information: Name of the Cat * Breed * Sex * FS MN Female (Intact) Male (Intact) Age * Hyperthyroid Data: Date hyperthyroidism diagnosed * Thyroid nodule? * Yes No Pretreatment T4/free T4 level * Currently on methimazole? * Yes No Past relevant history Current treatment(s) or medication(s) Previous treatment(s) or medication(s) Thank you, we will get back to you shortly. For veterinary use only
