RAI Therapy Referral Form

When referring your patient to our hospital, please complete this form and upload all pertinent medical records.

 

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

Approximate
In months/years, or birthdate
In kg

REQUIRED DOCUMENTATION / INFORMATION

Is your patient eating Y/D food? *

Chem 15/CBC/Lytes *

T4 Level measured *

Is the client unsure if treatment is the right fit? Please let us know so we can manage appropriately.


Security Question *