Hyperthyroid
I-131 THERAPY CONSENT
DATE: ___________
PATIENT NAME: ____________________
MRN: ________________ PHYSICIAN: __________________
PERCENT UPTAKE FOR TREATMENT: _______________
THERAPY DOSE REQUESTED: _____________BY: ___________________
1. More than one I-131 treatment may be necessary.
2. The risk of eventual hypothyroidism (underactive thyroid) is high, especially after treatment of Grave’s disease, and lifelong daily ingestion of a thyroid hormone tablet would then be necessary.
3. Long term follow up will be necessary.
4. Eye disease may worsen or develop after I-131 therapy. This is likely a coincidence, but we will monitor with you.
5. Rarely, there can be severe neck soreness, swelling, or tenderness or increase in hyperthyroid symptoms due to radiation. If this happens, call the Nuclear Medicine clinic.
PERMISSION TO USE RADIOISOTOPES FOR THERAPY
I authorize____________________________________and such assistants as they may designate, to administer a therapeutic dose of radioactive iodine (I-131) to_____________________________(myself or name of patient). The uncertainties and nature of this treatment, the risks of injury, and radiation precautions have been explained to me. I voluntarily accept the risks involved.
SIGNED:_________________________________________
WITNESS:________________________________________
(Patient or person authorized to consent for pati