Radioactive Iodine (I-131) Consent Form Owner Name(Required) First Last Phone(Required)Email(Required) Pet Name(Required) First Pet's Typical Demeanor(Required)Choose oneRelaxed/CalmSlightly AnxiousMildly AnxiousVery AnxiousFearful/HidesAggressive/DefensiveMandatory Consent Items (Required)*All boxes must be checked in order to submit this form.(Required) I understand the pet will have to be fasted (no food) for at least 8hrs prior to I-131 treatment. (Required) I understand that I need to arrive between 7:30 AM-8:30 AM on the scheduled Monday for my appointment. Not arriving on time may affect VSC’s ability to perform the treatment. (Required) I understand, if I-131 treatment is performed, my cat will be boarded in VSC’s nuclear medicine facility for a minimum of 6 days. Typical discharge is Saturday 10am-2pm. (Required) I understand VSC cannot receive any bedding, clothing, or toys from home for my pet. Any additional items such as food and treats will not be returned. (Required) I understand that if my pet needs daily medication, I will provide this for their stay. (The medication will be stored properly and returned at the end of the stay). (Required) I understand if my pet needs anti-anxiety medication prior to vet visits (e.g., Gabapentin), I will give the recommended dose prior to arrival. (Required) I understand if I have noticed any changes in pet's behavior or eating between now and day of appointment, I will notify Veterinary Imaging Services prior to appointment. Post-Treatment Procedures (at home)At the time of release, the radiologist will talk to the owner and explain the post-treatment procedures. For the first two weeks following treatment: 1. Limit close contact (holding close to your own neck, sleeping next to) with your cat to a maximum of 30 minutes per day per person. 2. Keep your cat indoors. Scoop urine and fecal clumps from the litter box twice daily. Use a flushable litter (We will provide one 10 lb. bag) and flush all clumps down the toilet. Avoid splashing and make sure the litter goes down after flushing. If you have a septic tank you cannot flush the litter down the toilet and must keep your cats waste in a double-line garbage bag in a remote area of the house for 80 days. After the 80 days you can throw this garbage bag away in your normal trash. 3. Always wear latex gloves (VIS will provide) when handling your cat’s waste products, bodily fluids and when cleaning the litter box. 4. Place gloves and any objects that have been in contact with your cat’s urine or feces in a double lined garbage bag in a remote area of the house away from children and other animals for 80 days. 5. Keep minors (those under 18 years old) and pregnant women from coming into contact with (and being at least 3 feet away from) your cat or its waste products. THIS INCLUDES WHEN TRANSPORTING YOUR CAT HOME AFTER THE I131. Keep your cat in a carrier during any transport to avoid contamination of your vehicle by your cat’s urine or feces. After this two week period, you and your cat can resume normal activities and you may stop flushing waste products. I understand following the I-131 treatment there will be a two week post-care required. I have read over the instructions and understand these recommendations.By signing below, I acknowledge I fully understand the radiation safety aspects associated with I-131 treatment.Name(Required) First Last Signature(Required) Reset signature Signature locked. Reset to sign again Date(Required) MM slash DD slash YYYY IF CLICKING SUBMIT BUTTON BELOW DOES NOT DISPLAY SUBMISSION SUCCESSFUL, PLEASE SCROLL UP, CORRECT ANY FIELDS HIGHLIGHTED IN RED, AND TRY AGAIN.
