Nutrition 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:
(Please limit your input to 4 rows of 60 characters each)
   
Client Name:
Patient Name:
Species:
Age:
Breed:
Sex:
Body Weight:
 Current:    Ideal:   
Body Condition Score (on a 9 point scale)
   
Previous Medical History (please include dates): (Please limit your input to 6 rows of 75 characters each.)
   
Current Medical Problems: (Please limit your input to 6 rows of 75 characters each.)
   
Current Medications: (Please limit your input to 6 rows of 75 characters each.)
   
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:
   
Previous Diets: (Please limit your input to 6 rows of 75 characters each.)
 Please include approximate dates that each food was fed along with the brand and flavor of foods.
Current Diet: (Please limit your input to 6 rows of 75 characters each.)
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/Restrictions (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: (Please limit your input to 4 rows of 60 characters each.)
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 $130 and the charge for extensive follow-up or diet reformulation is $80. These prices are current as of July 1, 2002, 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.
   
Each time you submit a consultation to our service, please call the VMTH, and leave a message for the Nutrition Support Service so we can ensure the case has been received.