Owner: _________________________

Address: ________________________

Phone: (Day)____________________

(Night)___________________

(Cell)____________________

Referring Veterinarian: _______________________________________

Referring hospital/clinic: ______________________________________

I authorize Dr. Gail Mason to hospitalize and treat the above-described cat with radioactive iodine (1-131). I understand that my cat will remain at this facility (PVS) after administration of radioiodine until the radiation levels have decreased sufficiently to permit release of my cat. Until this time, no visitation is permissible for human safety reasons. The radiation levels permitted are determined by the State of Maine radiation safety guidelines and regulations.

I understand that:

• My cat will be medically evaluated (including blood/urine tests, radiographs, and ultrasonography) to assess overall health status and eligibility for treatment.
• Though the radioiodine treatment is successful with one treatment 90-95% of the time, outcomes cannot be guaranteed. For any cats requiring re-treatment at PVS, the cost x~ii1l be one-half the original amount.
• Rarely, a small percentage of cats (<5%) develop an under-active thyroid (hypothyroidism) within a few months after treatment. This situation would require daily thyroid supplementation.

In the event of an emergency, I authorize the veterinarians at PVS to render such medical and/or surgical treatment as deemed necessary, and I accept financial responsibility for costs incurred.

I agree to follow discharge instructions that are provided to me and understand that pregnant women and children younger than eighteen should not have direct exposure to my treated cat for 2 weeks following hospital release.

Signature of Owner______________________________ Date_____________