Clinician Referral Form (Nutrition)

Clinician Referral Form (Nutrition)

Please note, for all non-assisted feeding consultations, the client will be contacted and communicated with directly. If possible, please let the client know to expect an email from us.
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 Friendship's Nutrition service (this is also the option for clinic staff referring their own personal pets)I am CLINIC STAFF referring a patient to Friendship's Nutrition service
STOP!
IF YOU ARE A CLIENT

wanting your pet seen by Friendship's Nutrition Service,

this is not the correct form. Please click to fill out the following form:

FHA Client Intake Form

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

Please note: filling out the wrong form will result in delayed responses and extend the intake process as we will need to send you the proper form.
We are currently scheduling 1-3 months out for all non-emergent appointments.
Is this an Assisted Feeding request?*

YesNo
ASSISTED FEEDING - INFORMATION
Services are vet-to-vet and do not involve client contact with the nutritionist.

We will compile a plan and send it to the referring clinician. Feel free to keep us updated and we will make change suggestions based on those updates. If you have any questions, please email nutrition@friendshiphospital.com.

NG/NE/E tube plans - $125
E/G tube plans - $216
PN or AA - dependent on size of patient, duration, and components

**If you want to utilize our Assisted Feeding service, please reach out to nutrition@friendshiphospital.com to get set up in our system**
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APPOINTMENT PRICING INFORMATION

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

New Client Appointment - $394/hr

Recheck Appointments* - $311/hr

*Certain recheck appointments may be with our medical techs.

Complex commercial plans and/or homemade diets are an additional $155-375+

Common example: $394 (Initial appt fee) + $327 (Homemade Diet fee, includes recheck) = $721

*For clients who are coming to our service after we have made an Assisted Feeding plan, we will deduct $50 from the initial appointment fee.*

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PLEASE NOTE:
We operate on a referral basis only and mainly via teleconsulting. Filling out this form constitutes as a referral and indicates that you have a veterinary-client-patient relationship with the referred pet/client. If you wish to discuss this patient without referral, please reach out to the email address below.

We may periodically send emails during the process of making the plans to clarify medical informaiton or (for assisted feeding plans) to clarify which diets you have on hand.

PLEASE be on the lookout for these emails.

We ask that any medical records or labs generated in the future for this pet get sent to us.

***

As we are a teaching hospital, there may be a rotating student intern participating or observing your client's appointment in addition to their board-certified doctor and medical nurse.

***

For owners with questions, please direct them to nutrition@friendshiphospital.com.

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Name of person filling out this Referral*
Date of Referral*

MonthDayYear
Date
Have you referred to us before?

YesNo
ASSISTED FEEDING ONLY

You MUST answer all questions here if requesting an assisted feeding plan.

ER FEE INFORMATION

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 of $248 may apply).

MEDICAL RECORDS

Complete records/labs MUST either be attached to the end of this form or sent to nutrition@friendshiphospital.com as soon as possible as we cannot do the plan until we have these. Thanks for understanding!

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
(Our plan cannot be completed without a date of discharge)

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, we cannot do the diet plan without this information filled in, thanks so much!):
Liquid Diets on site

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*

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*
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 e-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 appointment slots for appointments considered urgent by the referring veterinarian. Is this an urgent appointment? *
PET HISTORY
Current and past pertinent medical history*
Example: CKD, IRIS Stage 3 (normotensive, proteinuric)
Current medications/ supplements, dose, frequency*
Example: Fish oil, 980mg EPA+ DHA, q24 hr.
Current Appetite:*

NormalHyporexic (66-99%)Anorexic (< 66%)
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 YES to any, please describe frequency, predisposing factors (if known), treatments provided and response:
Additional Medical Notes (write N/A if none):*
Please include ALL email addresses this plan should go to (incl. any after hours staff; If no add'l emails needed, please write the main clinic email):*
Please upload medical records/labs here (or send them to nutrition@friendshiphospital.com).

If you are unable to upload, please email them to nutrition@friendshiphospital.com.
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Clinician Referral Form (Nutrition)

REFERRING CLINICIAN INFORMATION

CLIENT INFORMATION

PET INFORMATION

REFERRAL INFORMATION

PET HISTORY