Long-term Monitoring & Therapy: Forms & Documents

Appointment Documents

Patient Self-Reported History Form

Patient Self-Reported History Form

Laboratory Requisition

General endocrine lab slip.Laboratory Requisition

Ultrasound Requisition

Sample requisition for a thyroid and or neck ultrasound.Download Ultrasound Request

Diagnostic Testing Documents

Diagnostic rTSH-Stimulated 123-I Whole Body Scan and Serum Thyroglobulin

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Patient Instructions & Schedule

Diagnostic rTSH-Stimulated Serum Thyroglobulin Testing Only

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Patient Instructions & Schedule

Diagnostic rTSH-Stimulated PET/CT Scan and Serum Thyroglobulin

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Patient Instructions & Schedule

Radioiodine Therapy Documents

Patient Instructions

Low Iodine Diet Instructions
Pretreatment Instructions
Instructions on Treatment Day
Follow-up Recommendations
Steroid Treatment Instructions

131-Iodine Treatment Dose Selection Data Form

131-Iodine Treatment Dose Selection Data Form

Nuclear Medicine Pre-Treatment Scan Requisition

Nuclear Medicine Pre-Treatment Scan Requisition

Nuclear Medicine 131-I Treatment Requisition

Nuclear Medicine 131-I Treatment Requisition

Nuclear Medicine Post-Treatment Scan Requisition

Nuclear Medicine Post-Treatment Scan Requisition

Radioiodine Consent Form

Radioiodine Consent Form

Documentation of Radioactive Dose Administration

Documentation of Radioactive Dose Administration

Additional Radioiodine Therapy Documents

Radioiodine Therapy after Thyroid Hormone Withdrawal (with preceding 123-I Diagnostic Scan)

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Patient Instructions & Schedule

Radioiodine Therapy after Thyroid Hormone Withdrawal (with preceding 131-I Diagnostic Scan)
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Patient Instructions & Schedule

Dosimetric Radioiodine Treatment of Iodine-Avid Thyroid Cancer after Thyroid Hormone Withdrawal
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Schedule
Patient Instructions & Schedule

Radioiodine Therapy after rTSH (with preceding 123-I Diagnostic Scan)
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Schedule
Patient Instructions & Schedule

Radioiodine Therapy after rTSH (with preceding 131-I Diagnostic Scan)
Schedule

Schedule
Patient Instructions & Schedule

Dosimetric Radioiodine Treatment of Iodine-Avid Thyroid Cancer after rTSH

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Patient Instructions & Schedule

Physician Note Templates

Radioiodine Therapy after rTSH Preparation

Radioiodine Therapy after rTSH Preparation

Radioiodine Therapy after Thyroid Hormone Withdrawal-

Download Ablation Withdrawal Note

Follow-Up of Thyroid Cancer at Post-Treatment Scan (after Preparation with rTSH)

Follow-Up of Thyroid Cancer at Post-Treatment Scan (after Preparation with rTSH)

Follow-Up of Thyroid Cancer at Post-Treatment Scan (after Preparation with Thyroid Hormone Withdrawal)

Follow-Up of Thyroid Cancer at Post-Treatment Scan (after Preparation with Thyroid Hormone Withdrawal)

Follow-up of Treated Thyroid Cancer

Follow-up of Treated Thyroid Cancer

Follow-Up of Treated Thyroid Cancer after Recombinant TSH-Stimulated Testing

Follow-Up of Treated Thyroid Cancer after Recombinant TSH-Stimulated Testing