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Request for Clinical Nutrition Consultation

For veterinarian to complete

Clinic Information

How do you prefer to receive written communication?


Client Information

Patient Information

Gender

Spayed/Neutered

Please indicate in 'years' and 'months'. E.g., 2 years, 3 months.
Please indicate as 'x/9'. E.g., 6/9
Has your patient's weight changed recently?

Please indicate in 'kg' and/or 'lb'. E.g., 10 kgs, 22 lbs.
Was this change in weight intentional?
Please indicate in 'kg' and/or 'lb'. E.g., 10 kgs, 22 lbs.
Does your patient have evidence of muscle wasting?
If your patient's weight has changed, please indicate:
Indicate 'years', 'months', 'days'

Nutritional Goals for Patient

Please indicate all that apply.



If your goal is to obtain a balanced home-prepared diet, why is that your goal?



Please include with this request copies of relevant medical records and a recent complete blood count, serum chemistry, urinalysis, and any other pertinent diagnostics. Please request the pet’s owner to complete the appropriate diet history form as accurately as possible. All forms and supplemental information can be submitted using the contact information above. 

Please feel free to contact the Clinical Nutrition Service if you have any questions or concerns. Thank you.