Radioiodine Therapy Referral Form

When referring your patient to our hospital, please complete this form along with all pertinent medical records. If this is an emergency which requires treatment within 24 hours, please contact our Emergency Doctor Team directly, 506-387-4015 press option 8.

Also, please ensure that you contact the doctor that will be managing the case at Riverview Animal Health Centre to ensure continuity of care.

REFERRING VETERINARIAN INFORMATION

Name of Referring Veterinarian *

Name of Referring Hospital *

Phone Number *

Email Address *

PATIENT INFORMATION

Client's Name *

Client's Email Address *

Client's Phone Number *

Patient's Name *

Breed *

Age *

Sex *

Patient History – Include any adverse drug reactions, previous illness, or surgery. *

Please send medical records, including Radiographs.

Current treatments and response to therapy (attach all pertinent lab results) *

Please send medical records, including Radiographs.

Any additional comments:

Patient's Medical Records

Preferred Communication *

I would like a call from the Doctor.
Please book the appointment with the client.

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Radioiodine Therapy Referral Form

REFERRING VETERINARIAN INFORMATION

PATIENT INFORMATION

Our Cookies

About Cookies

Cookie settings

Functional cookies

Analytics cookies

Marketing cookies