Clinician Referral Form (Nutrition)

Clinician Referral Form (Nutrition)

For both vet-to-vet and client-to-vet services
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*
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.

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
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)
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)
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). If you have a contact number for this particular case, please also write it below.
Completed vet-to-vet/assisted feeding plans will be sent to the clinic ONLY. Please list any additional hospital email addresses that should be included (e.g. after-hour staff, technicians, etc). (Plans generated from appointments are sent to both clinic and owner)*
REFERRING CLINICIAN INFORMATION
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*
*** IMPORTANT: please make sure it is a clinic email NOT a personal email to ensure receipt. ***
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 (choose all that apply)*
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 weeks to 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, 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:
Current Appetite:*

NormalDecreasedSignificantly decreasedOther
Duration (Please specify days, weeks, months, years)
Please describe your main goals for referral:*
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 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.

Cancelof
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.

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.
Should be Empty:

Clinician Referral Form (Nutrition)

REFERRING CLINICIAN INFORMATION

CLIENT INFORMATION

PET INFORMATION

REFERRAL INFORMATION

PET HISTORY