Clinician Referral Form (Nutrition)

This is the veterinary referral form for Peak Veterinary Specialists PLLC (PVS). This form is to be used by a veterinarian or staff, for referral of a patient, an assisted feeding request or a vet-to-vet consult.

If you have any questions, our email is nutrition@peakveterinaryspecialists.com.

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/G tube plans
PN or AA - dependent on size of patient, duration, and components

Typical turnaround time: same-day

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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: 1-2 weeks. If more urgent, please indicate.

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2. NUTRITIONIST-TO-CLIENT SERVICES

Services are vet-to-client and begin with an appointment. Wait times typically 1-3 months, but please indicate if urgent.

New Client Appointment - $517. May include temporary homemade diet if medically indicated.

Recheck Appointments* - $326/hr

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

Common example:

$517 (Initial appt fee) + $326 (Homemade Diet fee) = $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 advisory 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 patient referral are you seeking? (See above for pricing and details.)*

Vet-to-vet: Assisted feeding (NG/NE/E/G/J- tube, PN. NO direct client contact)Vet-to-vet: Consult (NO direct client contact)Nutritionist-to-client: Patient referral for appointment

Name of person filling out this Referral*

You have chosen a 'vet to vet' consult that is NOT assisted feeding. Please note that these do NOT include client contact. While we try to complete these as soon as possible, a requested turnaround time can help us prioritize. Please describe your case:*

Urgent (expected <2 business days turnaround)Timely (expected <5 business days turnaround)No rush (expected 1-2 weeks)

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).

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

Is this pet expected to receive dialysis treatments?
Yes- dialysis is expected
No- dialysis is not expected

Estimated Date of Discharge:   Date of discharge
WHY: We typically start at QID feedings while in-hospital 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

Completed vet-to-vet/assisted feeding plans are sent to the clinic ONLY (not to owner). Please list any additional hospital email addresses that should be included (e.g. after-hour staff, technicians, etc). Please ensure the clinic email is checked for the plan.

List all liquid diets your hospital has in stock currently (WHY: we base our plans off in-stock liquid diets and they are not interchangeable. Please denote if the diet is FELINE and/or CANINE when appropriate)

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

YesNoUnsure

Please share the contact number for the clinician in charge of this case (texting number preferred). WHY: We may need clarification or to discuss options, and lack of a contact number can delay return of the plan or result in reformulation charges. *

Is this pet being referred by one of the following hospitals?*

Dr.*

First Last

Hospital/Clinic*

If you are referring for assisted feeding or vet-to-vet and your hospital is not listed, please ensure a Hospital Set Up form is completed first: https://form.jotform.com/223466012472046

Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Clinic Phone Number*

Please enter a valid phone number.

Clinic email for communication regarding this case*

*** IMPORTANT: please make sure it is a clinic email NOT a personal email to ensure receipt. ***

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 Name*

Canine/Feline*

CanineFeline

Pet Breed*

Pet Coat Color (if known)*

Pet Age*

Pet Birthdate*

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)*

Our appointment wait times can be weeks to months. However, we attempt to reserve priority appointment slots for cases considered urgent by the referring veterinarian. Is this an urgent case? *

Current and past pertinent medical history, a list of major diagnoses/concerns is sufficient*

Current medications/ supplements*

Does this pet have any known adverse or allergic reactions to medication(s)/food?*

If yes, please detail briefly:

It is assumed that referrals are for best nutritional recommendations, but if the clinician has specific goals/questions, please list them here:

Additional notes or considerations (can leave blank if not needed):

Please upload medical records/labs here. If needed, you can email them to nutrition@peakveterinaryspecialists.com. However, attaching them below is preferred.

Thank you for your referral! Please feel free to reach out anytime if you have a question about the process, a patient, or an update: nutrition@peakveterinaryspecialists.com.

If you do not receive communication by the previously state turnaround times, kindly email us to follow up.

Clients can also initiate the referral process by filling out the Dietary History form, available on our website. However, a Clinician Referral Form is required.

Clinician Referral Form (Nutrition)

REFERRING CLINICIAN INFORMATION

CLIENT INFORMATION

PET INFORMATION

PET HISTORY