arrow_back Back to Nutrition Nutrition Referral Form Referral form "*" indicates required fields Veterinarian Name* First Last State License Number*Clinic Name*Clinic Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Clinic Phone*Email* Pet InformationOwner Name* First Last Phone*Email* Pet's Name*Breed*Sex* Male Intact Male Neutered Female Intact Female Spayed Age*WeightUnitPoundsKilogramsDate Weighed* MM slash DD slash YYYY Muscle Condition Score* Normal Mild Moderate Severe Muscle Loss Body Condition Score (1-9)**Body condition score between 4-5 (out of 9) is considered idealPlease enter a number from 1 to 9.Please describe the clinical history of the case and the reason for the nutritional consultation.How would you describe the pet's appetite? Normal Increased Decreased Other Is the pet receiving any medications currently? Yes No Please provide medication name and dosage.Is the pet suffering from any gastrointestinal signs? Yes No Please describe:Have you sent medical records and laboratory results for the patient you are referring?* Yes No Thank you for the referral!Thank you for the referral! To avoid scheduling delays, please send medical records and laboratory results to [email protected].Referring Veterinarian Request for Nutrition Telemedicine Services As the undersigned veterinarian, I hereby provide consent for a telemedicine consultation with a board-certified veterinary nutritionist, in collaboration with a resident, as part of the veterinary care provided for the above-mentioned patient. The veterinary nutrition specialist may offer nutritional expertise and recommendations to enhance the overall care plan. Purpose: The objective of this telemedicine consultation is to leverage the expertise of a board-certified veterinary nutritionist to optimize nutritional management for the patient. Veterinarian-Client-Patient Relationship (VCPR): I affirm that I uphold the VCPR with the patient and owner, and I am responsible for overseeing the patient’s medical care. Telemedicine Consultation: Our board-certified veterinary nutritionist and/or resident can offer remote nutritional recommendations, advice, and guidance to enhance the overall veterinary care of your patient. These recommendations will be communicated to both you (the referring veterinarian) and the client through the nutrition report. We strongly encourage you to review the nutrition report carefully to ensure the comprehensive representation of the patient’s medical history and to identify any potential contraindications in the recommendations provided. Licensing: The board-certified veterinary nutritionist and resident may not be obligated to maintain an active veterinary medical license in the state where I practice or in the state where the patient or client resides.Consent* I acknowledge that I have read, understood, and agree to the terms outlined above.
