Hospital Account Set-Up Form

Hospital Account Set-Up Form
Thank you for your interest in Peak Veterinary Specialists' Nutrition Department's Vet-to-Vet program.

We're excited to be able to help locally, nationally, and internationally!

You ONLY need to fill out this form if 1) you are interested in vet-to-vet services (see below) and 2) your hospital is not set up already.

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Our 'nutrionist-to-client' services start with an appointment. Please fill out Clinical Referral form to initiate this process. You do not have to complete this form for these services.

Our 'vet-to-vet' services are below. Please note:
- These programs are for referring veterinarians
- These plans are vet-to-vet only and do NOT involve client contact with our nutrition team. If you would like us to connect directly with the client, please refer the patient for an appointment instead.
- Please note that follow-up nutrition appointments are generally recommended for clients and required if a client desires direct contact with the Nutrition team. If a client chooses to progress to a Nutrition appointment within 30 days, they will receive a $50 transfer-of-care credit.
Assisted Feeding PROGRAM INFORMATION:
- We create tailored nutrition plans for tube feeding (including NG/NE/E/G tubes) and critical care (including parental nutrition and ICU feeding) for small animals (we do not do avian/exotic nutrition).
- Written recommendations will be provided to the vet. The plans are usually sent the same day if submitted during working hours (M-F, Eastern time).
- If you do not receive a confirmation email from our staff, please email us directly. After-hour/urgent requests may be possible as our schedule allows, please contact us for emergency fees/requests.
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Vet-to-Vet Consult PROGRAM INFORMATION:
- We can create abbreviated nutrition recommendations for small animals (canine/feline). Recommendations are typically limited to our top commerical diet choices. A simple, temporary homemade diet may be made if medically indicated. Long-term or complex homemade diets are ideally referred for an appointment.
- These consults can be used if time to an appointment is prolonged and/or if there are financial concerns.
- Written recommendations will be provided to the vet. The plans are typically sent within 1 week, but if an urgent response is needed (e.g. hospitalized pet) please indicate this on the form. After-hour/urgent requests may be possible as our schedule allows, please contact us for emergency fees/requests.
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  To become established with our service, please fill out the following form. We will confirm and send you a price list.
  
  Please note: Filling this form out establishes your Clinic or Hospital with the Nutrition Department at Peak Veterinary Specialists. This is NOT the form to request plans for individual pets. If you need the Referral form for Assisted Feeding or general referral to our service, please click HERE.
  
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Clinic Information

Please fill out the following so we can make you an account in our system.
Are you an EVG network hospital?
Name of Clinic*
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
Clinic Email*
example@example.com
Phone Number
INTERNATIONAL Clinics: please put all 0's in this field and answer the "INTERNATIONAL Clinics" field.
INTERNATIONAL Clinics: if you have an international phone number, please type it below (including country code)
If you have a staff member who should be our primary contact for sending and receiving Assisted Feeding requests, please include their name and email below.

First NameLast Name
Email
example@example.com
Billing Information

Please fill out the following so we can set up billing.
Please read each section below and check to indicate it was read and understood.*

For assisted feeding requests & charged vet-to-vet consults, we bill the requesting hospital and then they can individually bill their clients.Bills will be sent to the hospital after each individual request.Payment is expected within 30 days. After 30 days, interest is accrued on outstanding balances and cannot be reversed.
Billing primary contact*

First NameLast Name
Billing Email (if different from general email; where we should be sending invoices)
example@example.com
Please note: Our system automatically is set up to send a reminder daily or every other day if there is an outstanding balance. Please make sure that the info you provide above is appropriate to receive both the invoices and reminders as we cannot separate which goes where.
On-Site Diets

Unless otherwise requested, our plans typically use diets that the referring hospital actively carries. Therefore, we require a list of diets kept on-site at the clinic (canned, dry, and liquid). We recommend keeping a running list on a document that can be shared or at least emailed to us so we can refer to it in real-time. For non-critical patients, we may also recommend diets that require ordering.
Ideally, we will have a shared live document via Sharepoint or similar to update in-stock diets. Please let us know if you have an option such as this that will be an accurate list of your diets. We will reach out to set it up further.
Other options: You can input a list of diets kept on-site at the clinic (canned, dry, and liquid) or attach a file below.
You can upload documents here, if desired.

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Name of person filling out form*

First NameLast Name
Position at Clinic*
Should be Empty:

Hospital Account Set-Up Form

Clinic Information

Billing Information

On-Site Diets