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Clinical Nutrition Service Referring Veterinarian Form

Clinical Nutrition Service Referring Veterinarian Form

"*" indicates required fields

Veterinarian’s Information

Veterinarian's Name*

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.*

I understand

Veterinary Hospital Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

IMPORTANT: We will include the above email address on all email communications with the owner of the patient.*

I understand

Pet Owner's Information

Name*

First Last

Primary Phone*

Secondary Phone

Email*

Patient’s Information

Patient’s First and Last Name*

First Last

Type of Pet*

Dog

Cat

Breed*

Age

Years*

Months*

Gender*

Female Intact

Female Spayed

Male Intact

Male Castrated (i.e. Neutered)

Current Weight*

(please specify pounds or kilograms)

What was the approximate date this patient was last weighed at your Veterinary Hospital?*

Would you consider your patient to be?*

Overweight

Ideal weight

Underweight

Select a body condition score for your patient from 1 to 9 based on the charts above:*

1

2

3

4

5

6

7

8

9

Select a muscle condition score for your patient based on the charts above:*

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?)*

Please summarize your patient’s medical conditions:*

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

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

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.*

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.*

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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