Clinician Referral Form (Nutrition)

Clinician Referral Form (Nutrition)

For both vet-to-vet and client-to-vet services
Dr. Bullen and Dr. Luisana are proud to announce that, beginning in December 2024, management of the Nutrition Service at Friendship Hospital for Animals will branch off as Peak Veterinary Specialists (PVS). PVS will still be supporting not just Friendship, but all of the EVG Network hospitals as well as other veterinary corporations and universities. Contact us if you are interested in more information regarding our hospital subscription services.

There are no major changes outside of communications and billing. Our new email is nutrition@peakveterinaryspecialists.com.

Currently, new patient appointments are being scheduled in February 2025. If you feel your patient should not wait, please reach out for a vet-to-vet consult.
Are you a client wanting your pet seen or a veterinary clinic filling out this referral for one of your patients?

I am a CLIENT wanting my pet to be seen by PVS Nutrition service (this is also the option for clinic staff referring their own personal pets)I am CLINIC STAFF referring a patient to PVS Nutrition service
STOP!
IF YOU ARE A CLIENT wanting your pet seen by Peak Veterinary Specialists, this is not the correct form. Please click to fill out the following form:

PVS Client Intake Form

(https://form.jotform.com/222785378340058)
SERVICES OFFERED:

1. VET-TO-VET SERVICES

The following services are vet-to-vet and do not involve client contact with the nutritionist.

Plans are emailed to the referring clinician. Clients that proceed with an appointment will receive a $50 discount. Price list will be emailed after Hospital Set Up Form is completed.

a. Assisted Feeding
NG/NE/E tube plans
E/G tube plans
PN or AA - dependent on size of patient, duration, and components

Typical turnaround time: same-day

**If you want to utilize our Assisted Feeding or vet-to-vet service, please see form at https://form.jotform.com/Nutrition_PVS/PVS-hosp-account-set-up-form to be set up in our system**
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b. Vet-to-Vet Consults

Includes: Basic written recommendations for any case.

We review records and write abbreviated recommendations. Does not include communication to client. Recommendations are typically commercial diets but a simple/temporary homemade diet may be provided if medically indicated. Can be used as an intermediate step to get some recommendations quickly if wait-times for initial appointments are prolonged.

Typical turnaround time: in one week. If more urgent, please indicate.

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2. NUTRITIONIST-TO-CLIENT SERVICES

Services are vet-to-client and begin with an appointment

New Client Appointment - $517

Recheck Appointments* - $326/hr

Complex commercial plans and/or tailored homemade diets are an additional $155-420+

Common example:

$517 (Initial appt fee) + $326 (Homemade Diet fee, includes recheck) = $843

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PLEASE NOTE:
We operate on a referral basis only and we are remote only. Filling out this form constitutes a referral and indicates that you have a veterinary-client-patient relationship with the referred pet/client. Note that we may recommend therapeutic diets, medications, and/or further diagnostics. We are a support service and defer urgent care and/or final decisions regarding a pet's treatment to the referring/supervising veterinarian(s). If you wish to discuss a patient without referral, please reach out to the email address below. Thank you for your referrals and please always feel free to reach out if you have a question.

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What type of referral would you like (see above for pricing and details):*

Vet-to-vet: Assisted feeding (e.g. e-tube)Vet-to-vet: ConsultNutritionist-to-client: Patient referral for appointment
Name of person filling out this Referral*
Date of Referral*

MonthDayYear
Date
Have you referred to us before?

YesNo- if submitting an assisted
ASSISTED FEEDING ONLY

We strive to return assisted feeding plans same-day. However, on certain busy clinic days and after 2/3 PM ET, this cannot always be promised. If needed same day, please contact us and we will do our best to accommodate (ER fee may apply).

MEDICAL RECORDS: Please attach to the end of this form or email.

Is the pet currently hospitalized?:
Yes - the pet is currently hospitalized
No - the pet is not currently hospitalized

Is this pet on Dialysis?
Yes - This pet is or will be on Dialysis
No - This pet is not on or will not need Dialysis

Estimated Date of Discharge:   Date of discharge
We tend to start at QID feedings and switch to TID feedings after discharge unless otherwise requested.

What type AND size of feeding tube is being used (eg- 18fr e-tube)?:Type/side of tube
List all liquid diets your hospital has in stock currently (required & please denote if the diet is FELINE and/or CANINE when appropriate)
Liquid Diets on site

Would this client be able/willing to purchase a diet that is not in-stock at your hospital, if needed?

   Yes   No   Unsure

If your hospital is not established with our service, OR you have any out-of-stock and/or new diets from your previous list, please write your diets here or email us:

Out of stock (liquid and commercial)
New diets (liquid and commercial)

Please note: If you've not been established as a clinic we do Assisted Feeding plans for, please also fill out the following Hospital Set Up Form:
https://form.jotform.com/223466012472046
REFERRING CLINICIAN INFORMATION
Is this pet being referred by a EVG network hospital?*
Dr.*
First Last
Hospital/Clinic*
Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinic Phone Number*
Please enter a valid phone number.
Clinic Email*
*** IMPORTANT: please make sure it is a clinic email NOT a personal email. (This includes VCAs, BluePearls, Banfields, and hospitals in the EVG network) ***
CLIENT INFORMATION
Client/Owner Name*

First NameLast Name
Client/Owner 2 (if more than one owner)

First NameLast Name (this is especially important if there might be records under a different last name at other clinics)
Address (not needed for Vet-to Vet Consults or Assisted Feeding)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
INTERNATIONAL PHONE NUMBERS: If you have an international phone number, please type it below (including country code):
Email*
example@example.com
PET INFORMATION
Pet Name*
Canine/Feline*

CanineFeline
Pet Breed*
Pet Coat Color (if known)*
Pet Age*
Pet Birthdate*

MonthDayYear
Date
Pet Neuter Status*
Pet's Body Weight (in kilograms)*
Please note: If this is not accurate, it could result in incorrect recommendations
Unit of measurement for weight*
Please note: If this is not accurate, it could result in incorrect recommendations
Pet's Muscle Mass*
Body Condition (__/9)*
REFERRAL INFORMATION
Reason for Referral*
Please note: selecting "Assisted Feeding" means you're asking for an feeding tube plan for a patient.
If you chose 'Other' please explain:
Our appointment wait times can be at least 3-4 months. However, we attempt to reserve priority appointment slots for cases considered urgent by the referring veterinarian. Is this an urgent case? *
PET HISTORY
Current and past pertinent medical history*
Example: CKD, IRIS Stage 3 (normotensive, proteinuric)
Current medications/ supplements*
Example: Fish oil, 980mg EPA+ DHA, q24 hr.
Does this pet have any known adverse or allergic reactions to medication(s)/food?*
If yes, please detail briefly:
Current Appetite:*

NormalDecreasedSignificantly decreasedOther
Duration (Please specify days, weeks, months, years)
Pet or owner dietary preferences (ex: prefers canned diets; does not want carrots, etc):*
Have there been any unintended changes in body weight?*

NoYes - GainedYes - Lost
Gained or lost:   Gained   Lost,
How much weight?: Weight change amount
Unit of measure: kgs   lbs
Over a course of how long?  Days  Weeks   Months   Years
Has the pet experienced any VOMITING?*

YesNo
If Yes, for Number of Days Weeks Months Years
Has the pet experienced any REGURGITATION?*

YesNo
If Yes, for Number of Days Weeks Months Years
Has the pet experienced any DIARRHEA?*

YesNo
If Yes, for Number of Days Weeks Months Years
If the patient has had GI signs (vomiting/regurgitation/diarrhea), please describe frequency, predisposing factors (if known), treatments provided and response:
Additional Medical Notes (write N/A if none):
Plans will be emailed to the main clinic email provided above. Please list any other hospital email addresses that should be included (e.g. after-hour staff, technicians, etc). If you have a phone number that can be used as a point of contact for this particular case, please write it below:*
Please upload medical records/labs here. If needed, you can email them to nutrition@peakveterinaryspecialists.com. However, attaching them below is preferred.

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Clinician Referral Form (Nutrition)

REFERRING CLINICIAN INFORMATION

CLIENT INFORMATION

PET INFORMATION

REFERRAL INFORMATION

PET HISTORY