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Your email here:
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Subject
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1. Clinic State
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(2-letter - ex. Alabama = AL)
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2. City Population
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3. Number of Patients Seen Annually:
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4. Feline Breed:
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Domestic shorthair
Domestic mediumhair
Domestic longhair
Abyssinian
Burmese
Himalayan
Mancoon
Persian
Russian Blue
Rex
Siamese
Other
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4a. If other, please state breed:
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5. Weight of Cat:
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(please specify unit - kg or lb)
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6. Gender of Cat:
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Female intact
Female spayed
Male intact
Male castrated
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7. Age of Cat:
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8. Which drug preparation is this cat receiving?
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Amitryptylline
Buprenorphine
Enrofloxacin
Methimazole
Metronidazole
Prednisolone
Prednisone
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9. How is the drug administered?
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As A Transdermal Gel
Orally - Tablet
Orally - Syrup
Orally - Capsule
Other
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10. Regarding the drug preparation, choose the best descriptor:
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finished(approved)brand-name dosing form
finished(approved)generic dosing form
compounded in-house
compounded by a local pharmacist
compounded by an internet pharmacist
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11. If you selected a transdermal gel (TDG) product for this animal, what was this decision based on: (select all that apply)
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1) Anticipated client compliance
2) Client request
3) Cost
4) Fractious pet
5) Intolerance to oral medication
6) Previous successful outcome
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11a. Based on your selection(s) above, which one was most important in your decision to use a TDG?
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1) Anticipated client compliance
2) Client request
3) Cost
4) Fractious pet
5) Intolerance to oral medication
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12. Site of treatment for transdermal gel?
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inside pinna
abdomen
other
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12a. What is the dosage (please specify mg/kg)?
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12b. What is the frequency of dosing each day?
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sid (once per day)
bid (twice per day)
tid (three times per day)
qid (four times per day)
prn (as needed)
other
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13. For what condition is this medication prescribed? (select all that apply)
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Allergy
Behavioral modification
Dysuria
Pain Management
Immune Mediated Disease
Infection
Inflammation
Hyperthyroidism
IBD
Other
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13a. If other, please describe:
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13b. What is the specific diagnosis?
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13c. If you selected "Pain Management" in 13, please state source and location of pain:
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14. How long has the cat received this medication?
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(please specify days/weeks)
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15. How has the patient responded to this drug?
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16. Is this cat receiving any other medications? If so, please describe, including the duration of treatment
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17. Indicate the timing of your peak sample collection (hrs post administration):
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1
2
3
4
5
6
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18. Indicate the timing of your trough sample collection (hrs post administration):
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9
10
11
12
14
20
21
22
23
24
other
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18a. If other, please describe:
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19. What is the date that this drug preparation was compounded?
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20. What is the cited expiration date of this preparation?
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21. What are the recommended storage conditions for this preparation?
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22. Please provide preferred contact information below: (can include name, phone, etc.)
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23. Please list any other drugs prescribed as transdermal gels that you would like to have tested?
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