Veterinarian Nutrition Service Request Form

Nutrition Service
Veterinary Teaching Hospital
245 Duck Pond Drive
Blacksburg, VA 24061
Email: vthpatientservices@vt.edu
Phone: 540-231-1775
Fax: 540-231-9354

Nutrition Service Requested

In-House Nutrition Appointment (client and patient come to VTH) + Nutrition Recommendation ($330)

Due to COVID-19, In-House Nutrition Appointments are not offered at this time.
Includes a 1 hour nutrition appointment ($130) and written nutrition recommendation* ($200). Client and patient meet the Nutrition Service at the VTH. Payable by client at the conclusion of the appointment.

Remote Nutrition Appointment (phone/video conversation with client) + Nutrition Recommendation ($330)

Includes a 1 hour nutrition appointment ($130) and written nutrition recommendation* ($200). Client and the Nutrition Service meet by phone or Zoom. Payable by client prior to the appointment.

Nutrition Recommendation only (currently internal referrals only) $200

Due to a high Remote Nutrition Appointment caseload, we are unable to offer external Nutrition Recommendation unpaired with an appointment at this time.
Includes written nutrition recommendation*; no direct communication with the client. Invoiced to the Veterinarian/Clinic.

* Written nutrition recommendation include a single recipe/ration or commercial recommendation. Additional fees apply for multiple recipes/rations or reformulations ($50 each for minor addition/reformulation; $100 each for major addition/reformulation).

Due to current scientific literature and in alignment with AAHA, ACVN, AVMA, CDC and FDA, we will not recommend a raw meat-based diet for pets. The primary concern is zoonotic pathogens, namely Salmonella and Listeria.

Client Information

Patient/Animal Information

Referring Veterinarian / Clinic Information

Patient Case History

State the primary problem(s) and/or concern(s) relative to nutrition request.

Please list medications (name) pertinent to the primary problem(s) and supplements (name and manufacturer) that the patient currently takes.

Please attach lab work related to the primary problem(s). If lab values are written below, please include reference ranges. Please do not attach the patient's medical record.

What are the goals of the nurtition request (i.e. problem(s) we should prioritize and/or specific aspects of the diet on which we should focus)? Are there special requests for diet (i.e. specific ingredients to include or avoid)?

Attachments / Additional Records

Have additional records been faxed?
Have additional images or records been sent with the client?
Attach Files / Images