Nutrition consult referral form for veterinarians

Name

Email

Veterinary Clinic

Phone

Address

Is the consultation urgent? Urgent consultations can be completed within 24 hours for an additional fee of $200.00 AUD incl. GST.

I would prefer the following (please select one option):

Email the completed referral letter and recipes to the referring vet only
Email the completed referral letter and recipes to the referring vet and the owner

Patient's name (please include surname

Species

Breed

Age

Sex

Patient's body condition score (BCS) - A score of 5/9 or 4/9 is considered ideal.

Patient's current weight (in kilograms)

Patient's muscle condition score

Please provide a brief summary of the medical history and diagnoses for this patient.

Does the patient currently have a good appetite?

Has the patient's weight been stable?

Please list all current medications (including doses)

Is a novel protein diet required?

If possible, please list protein and carbohydrate options that are novel to this patient.

Is there anything else we should know about this patient?

I would prefer the following (please select one)

If option 2, please provide the owner's full name, email address, phone number and postal address for the tax invoice.

By checking this box, you acknowledge that you have read and understand the information regarding our referral process including payment criteria

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