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Clinical Nutrition Service Referring Veterinarian Form
Clinical Nutrition Service Referring Veterinarian Form
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*
" indicates required fields
Veterinarian’s Information
Veterinarian's Name
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By submitting this referral to the University of Georgia College of Veterinary Medicine’s Clinical Nutrition Service, it signifies the referring veterinarian listed above has an established veterinarian-client-patient relationship (VCPR) for the patient listed below and authorizes members of the Clinical Nutrition Service to perform telemedicine consulting, including but not limited to email, videoconference, and phone communications, directly with the owner of the patient.
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I understand
Veterinary Hospital Name
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Address
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Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
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Email
*
IMPORTANT: We will include the above email address on all email communications with the owner of the patient.
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I understand
Pet Owner's Information
Name
*
First
Last
Primary Phone
*
Secondary Phone
Email
*
Patient’s Information
Patient’s First and Last Name
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First
Last
Type of Pet
*
Dog
Cat
Breed
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Age
Years
*
Months
*
Gender
*
Female Intact
Female Spayed
Male Intact
Male Castrated (i.e. Neutered)
Current Weight
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(please specify pounds or kilograms)
What was the approximate date this patient was last weighed at your Veterinary Hospital?
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Would you consider your patient to be?
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Overweight
Ideal weight
Underweight
Select a body condition score for your patient from 1 to 9 based on the charts above:
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1
2
3
4
5
6
7
8
9
Select a muscle condition score for your patient based on the charts above:
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Normal muscle
Mild muscle loss
Moderate muscle loss
Severe muscle loss
What is the PRIMARY REASON for the consultation? (i.e. What are your goals for your patient?)
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Please summarize your patient’s medical conditions:
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Please list any medications your patient is currently receiving or type “NONE” on the first line if the patient is not receiving any medications:
Medication
Amount
Frequency
Add
Remove
Please list any supplements (e.g. probiotics, fat supplements, joint support supplements, vitamin and mineral supplements, etc.) you have recommended for your patient or type “NONE” on the first line if you have not recommended any supplements:
Supplement
Amount
Frequency
Add
Remove
Final Acknowledgements
Appointment Availability: By checking this box, I acknowledge that this service is not meant to assist with severely ill patients with emergent or urgent nutritional needs as our next available telemedicine appointment is typically at least 30-days out from the time we receive all relevant forms and medical information from the client.
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I understand
Education: By checking this box, I understand that the University of Georgia College of Veterinary Medicine is involved in educational activities and that faculty, residents, interns, and students will be involved in my patient’s care.
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I understand
The undersigned certifies that he/she has read the above or has had the above read to him/her, and that he/she understands and fully accepts its terms.
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