Referring Veterinarian Nutrition Consultation Request Clinical Nutrition Service

North Carolina State University College of Veterinary Medicine
1060 William Moore Dr., Raleigh, NC 27606

Phone 919-513-6871 Fax 919-513-6905
Email: NCSUVetNutrition@gmail.com

Veterinarian Information: Dr. Hospital Street address City State Zip code Phone# Fax# Email

Pet Owner Information First and Last name Street address City State Zip code Phone# Fax# Email

Nutrition Services Requested: Our turnaround time is 10 business days or less once this request and all of the pertinent medical record information has been received.

Commercial diet options. List sent to Veterinarian at no charge.

Homemade diet: Formulation sent to Veterinarian only who will do all of the client communication; $205 charged to veterinarian

Reformulation $77

Assisted (tube) Feeding Recommendations $77

Pet Information Name Weight (STATE lbs or kgs) Body Condition Score /9 Species

Canine

Feline

Gender status

Breed DOB Age Environment

exclusively indoor

exclusively outdoor

mostly indoor

mostly outdoor

Work/exercise: Please describe the type of work or exercise this pet does on average per week

Do you want us to send the owner a homemade diet questionnaire:

Yes

Please summarize the medical problems and fax us the most pertinent medical record.

Diagnosis or rule out list Pertinent medical history Current Medications (name and dose per day)

Diagnostic test performed. Please attach or fax the most pertinent aspects of (not the entire) the medical record.

Pending test results

CBC

Chemistry Profile

Cytology

Biopsy

Stone Analysis

US/Rad report

Diet History

List commercial diets tried
Dry, Moist, or Wet	Brand	Flavor	Cups fed per meal*	# meals per day
Example: Dry	Purina	Lamb and Rice	1	3

List current diet(s) fed and please state why the diet is NOT satisfactory List current ingredients or foods to be included in homemade formulation or our commercial recommendations: