You and your veterinarian are assessing the suitability of treating your dog with Synovetin OA® in one or more arthritic joints. Synovetin OA®, a radio-therapeutic treatment, emits ionizing radiation within the joint to relieve pain and inflammation over an extended time period. Your dog’s coat and surroundings will not be affected, and the activity will naturally decrease over time. To maintain overall exposure below federally established limits, there will be certain procedures to follow in the period after treatment.

Initial Information

Owner Name *

Email *

Date *

Pet Name *

Date *

Person Interviewed *

Owner
Other

Owner

Other

Household Member Information

Household members

Sex *

Age *

General Contact Information

Describe each household member’s interaction(s) with your dog (direct, close and intermediate activities – as defined below the following table)

Person 1

Activity and type of contact involved (direct, close or intermediate) *

Duration *

Direct activities are <1ft (e.g., carrying the dog where the elbow is in contact or lap sitting where the elbow is directly on the torso). Close activities are at 1ft (e.g., feeding, grooming, sleeping, and routine lap-sitting) Intermediate activities are at 3ft (e.g., walking, jogging, and officing).

Person 2

Activity and type of contact involved (direct, close or intermediate) *

Duration *

Add additional pages for other household members, if necessary.

Can interactions with children and pregnant women be modified to minimize close contact with the dog? *

Yes
No
N/A

If the answer to the above question is yes, describe proposed modifications *

Does your dog currently sleep in the same bed with any household members? *

Yes
No

If yes, can arrangements be made to avoid this for the duration indicated on the Release Instructions? *

Yes
No
N/A

If the answer to the above question is yes, describe proposed modifications *

Is your pet mobile enough to climb stairs and/or enter and exit a vehicle independently? *

Yes
No
N/A

If the answer to the above question is no, provide the owner with additional strategies *

Does your dog jump up to beds or furniture with family members, or lap sit? *

Yes
No

If yes, can arrangements be made to avoid this for the duration indicated on the Release Instructions (i.e., not lap sit)? *

Yes
No
N/A

If the answer to the above question is yes, describe proposed modifications *

Does your dog currently sit in very close proximity (i.e., next to your chair or at your feet) to you for more than 3 hours per day? *

Yes
No

If yes, can arrangements be made to avoid this for the indicated time frames on the Release Instructions? *

Yes
No
N/A

If the answer to the above question is yes, describe proposed modifications *

Has the owner been provided with an example Release Instructions sheet? *

Yes
No

Does the owner fully understand the procedure they have arranged for their pet? *

Yes
No

Are you and your household members able and willing to modify your routine interaction with your pet for the time frames indicated on the Release Instructions? *

Yes
No

If the answer to the above question is yes, describe proposed modifications *

*Any “No” checkmark may be contraindicated for the procedure. Contraindication is based on owner responses, proposed dose to pet, or other clinical factors

Additional Items Discussed with Animal Owner(s)

Release Instructions / ALARA considerations *

Comments

Importance of modifying time and distance from pet *

Comments

Sleeping arrangements *

Comments

Added precaution for children and pregnant women *

Comments

What to do if their pet dies or needs medical attention *

Comments

Transport/carrying techniques to minimize contact *

Comments

Other: (such as 1 animal treated per house per year, boarding, traveling, commercial grooming, or tactile treatment) *

Comments

Name of Owner or interviewee *

Signature *

Clear Signature

Date *

Use the above table to fill in the duration (number of weeks) in the following Release Instructions. Assess the duration for each household member that has substantial interaction with the dog. Use the greatest duration value (weeks) in the Release Instructions. For example, if the table indicates a duration of 2 weeks for Person #1 and 3 weeks for Person #2, insert 3 weeks in the Release Instructions. Determination of which dog/owner behavior is decided upon owner answers to the Pre-Screening Questionnaire.

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Synovetin Pre-Screening Form