VMTH Nutrition Consult Request Form

Nutrition Online Consult Request Form©
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To:	Nutrition Support Service
	Veterinary Medical Teaching Hospital
	University of California, Davis
	One Shields Avenue
	Davis, CA 95616-8747
Fax:	(530) 752-7901
Voice:	(530) 752-1387

DVM:
Clinic:
Address1:
Address2:
Address3:
Fax:
Voice:

Reason for Consult Request: (please check one)

	Balance current home-cooked diet (Please attach a list of ingredients with amounts fed daily)
	Formulate home-cooked diet, because no commercial diet available to meet pet's needs
	Patient finds commercial diets unpalatable
	Other, please specify in 'Comments' box:
Comments:

Client Name:
Patient Name:
Species:
Age:
Breed:
Sex:
Body Weight:	Current: Ideal:
Body Condition Score:	1 2 3 4 5 6 7 8 9

Previous Medical History (please include dates):


Current Medical Problems:


Current Medications:


Laboratory Abnormalities: Please send copies of laboratory reports (such as recent CBC, Chem Panel, UA,and other diagnostic reports). We freqently need them to initiate the consult.

Does the pet have a good appetite?

Typically:

Currently:

Dietary History: (please include brand or type of food fed, quantity of food fed, frequency of feeding on a daily basis, and approximate dates that each food was fed)

Previous Diets:
	Please include approximate dates that each food was fed along with the brand and flavor of foods.

Current Diet:
	Please include date began feeding, brand and flavor of food, the quantity of food and frequency of feeding on a DAILY basis. If a homemade diet is being fed, please provide exact amounts of each ingredient fed DAILY.

Patient Dietary Preferences (What ingredients will/can the patient be willing to eat?):

Protein Sources		Carbohydrate Sources
beef	pork	barley	potato, white
chicken	salmon	millet	quinoa
cottage cheese	tofu	oatmeal	rice,brown
crab	tuna	pasta, spaghetti	rice, white
egg	turkey	peas, green	tapioca
lamb	whitefish	potato, sweet

Other Pertinent Information:

If diet formulation is needed due to an adverse reaction to food(s), please provide us with some options of protein and carbohydrate sources that are both palatable AND tolerated by your patient.This will need to be determined prior to submitting this consult.

Thank you for your request. We will contact you with follow-up questions as needed. Once all of the necessary information to complete the consult is received, the turnaround time is approximately 2 weeks. Our charge for formulating new diets is $200 and the charge for extensive follow-up or diet reformulation is $140. These prices are current as of July 1, 2008, but are subject to change in the future. Per VMTH billing policy, once the consult has been completed, the name of the client and your clinic name will be forwarded to the Small Animal Cashier’s Office. Invoices will be sent directly to your clinic by the Small Animal Cashier’s Office. Do not send payment prior to receiving the invoice. Please call us if you have any additional questions or concerns.