Download Referral form REFERRING VETERINARIAN INFORMATION

Referral form
Fill up this referral form and e-mail to:
Click to send the form once filled up
[email protected]
Fields marked * must be filled up
Date:
REFERRING VETERINARIAN INFORMATION
NAME*: Dr.
CLINIC:
CONTACT E-MAIL*:
PHONE:
if you prefer to be contacted by phone, please indicate the best day and time
CLINIC’S ADDRESS*:
PATIENT INFORMATION
PATIENT’S NAME*:
SPECIES*: dog
CLIENT’S LAST NAME*:
BREED*:
AGE*:
SEX/NEUTER STATUS*: neutered male
REASON FOR CONSULT:
SUMMARY OF THE MEDICAL HISTORY*: Attach all necessary clinical information and send it to us along with this form:
history, lab work (the most recent lab work) and other diagnostic tests
CURRENT CLINICAL CONDITION*: Current clinical condition and final diagnostic
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CURRENT MEDICATIONS: Include all current medications, dose, and length of treatment
OTHER COMMENTS: List other important comments regarding the patient
PATIENT’S NUTRITIONAL EVALUATION
At the end of this form you can find the body and the muscle condition scores for your convenience
BODY CONDITION SCORE*: score according to the attached scale
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MUSCLE CONDITION SCORE*: score according to the attached scale
Normal
Mild
Moderate
Severe
CURRENT BODY WEIGHT*:
kg
NORMAL BODY WEIGHT: Write the usual body weight that the patient has (or a body weight history, if available)
ENVIRONMENT
The patient lives:  indoor  outdoor
Does the patient live with other pets? (specify them)
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How much exercise does the patient get:
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Very little
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2-3 walks per day, 20 to 60 minutes per walk
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Large backyard always available
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Long outdor walks/runs 1-2 times per week
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Other:
FEEDING MANAGEMENT
The patient:
 Has free and constant access to food
 Eats once a day
 Eats twice a day
 Eats three or more times a day
 Other:
¿Does the patient have access to other food sources? ¿Which ones?
NUTRITIONAL RISK FACTORS
Have you seen any of these changes in your patient?
 Weight loss
 Weight gain
 Decreased appetite/food intake
 Increased appetite/food intake
 Decreased thirst/water intake
 Increased thirst/water intake
 Other:
If you have answered yes to any of the above, since when?
Have you seen changes in stool quality?

No

Harder faeces

Softer faeces

Blood/mucus
If you have answered yes to any of the above, since when?
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Does the patient show

Problems with mastication

Problems with swallowing

Food allergies/intolerances
If yes, indicate to which ingredients:
CURRENT DIET
Please, indicate all the foods consumed daily by the patient, with detail and precision, in the table
below. It is important to write the brand and amount fed of all commercial foods (including treats)
that are currently being fed. Please include all products intended for human consumption that
are fed as treats and table scraps. If your patient is eating a homemade diet, please specify the
ingredients, cooking method, and amounts fed daily. Some examples are presented in the table.
BRAND
Affinity Advance
TYPE
Adult Medium Pollo y Arroz
FORM
DAILY AMOUNT
FREQUENCY OF
FEEDING
SINCE WHEN IS THIS
FED
Kibble
200 grams
Twice a day
Since 3 years ago
150 grams
Once a day
Since 6 months ago
Two pouches per
day
Twice a day
4 years ago after
veterinary
prescription
Boiled chicken breast, meat
only
Royal Canin
Renal Special
Pouch
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CURRENT SUPPLEMENTS
Please, write down the nutritional supplements offered to the patient currently (or up to 3 months
ago) (for example: joint supplements, fatty acids for the skin, etc), including dosage, since when
are they fed and who prescribed them.
e.g..: Cosequin, 2 tablets per day, since 6 months ago, prescribed by his veterinarian
PREVIOUS DIETS AND SUPPLEMENTS
Please, use the table below to list the brand and type of diets/supplements fed in the past, including period
of administration, and reason for stopping. THIS IS PARTICULARLY IMPORTANT IN PATIENTS WITH
SUSPECTED ADVERSE FOOD REACTIONS.
e.g.: Royal Canin Hypoallergenic canine dry, January 2013 to March 2013, prescribed by veterinarian due
to diarrhoea, stopped because diarrhoea did not improve. .
e.g.: Eukanuba puppy dry, until one year ago, when the patient became an adult
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If you request a homemade diet, please fill out the next section:
TOLERANCE/PREFERENCE If you request a homemade diet indicate the ingredients tolerated and preferred by
the patient. E.g.: chicken breast: tolerated and palatable
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If you have preferences for certain ingredients list them here:
If you are requesting a weight loss plan, fill up this section:
Regarding treats:

Treats are not a part of the feeding plan

I wish to include treats in the weight loss plan
Specify the treats you would prefer to be included in the plan:
Do you have any preference regarding the brand of the veterinary weight loss diet to be used?
Thank you for your help, this information is very important to evaluate the patient and recommend the best
nutritional plan for the patient
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Global Nutrition Committee Toolkit provided courtesy of the
World Small Animal Veterinary Association– available:
http://www.wsava.org/nutrition-toolkit
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