Nutrition Consult Request Form - Veterinary Medical Teaching Hospital - 服务流程与费用说明

Sep 1, 2026

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Nutrition Support Service的营养咨询申请表用于兽医主诊医师与宠物主人提交营养支持评估需求。表格要求勾选并提供饮食史、血常规、生化（含T4如适用）、尿检及必要的既往医学记录，并强调化验需在6个月内保持时效。申请需说明原因与紧急程度、可否直接联系、宠物体况评分与当前疾病及用药信息。服务费用含营养评估与配方制定，并规定追加随访计费、配方不耐受的6个月内一次免费复配条件。

LanguageEnglish

CategoryForms

FormatDOCX

Pages3

Reading Time1 min

AccessFree to download

Consultation request requirements

Required documents and current labwork

Reason for request and urgency

Client and pet information

Condition scores and medical background

Fees and billing notes

Nutrition Consult Request Form© Nutrition Support Service Veterinary Medical Teaching Hospital One Shields Ave, Davis, CA 95616-8747 Ph: 530-752-7892 Email: nssvetmed@ucdavis.edu DVM: Clinic: Address: Phone: Email : Date: We require the following to proceed with the consult: (Please check) Nutrition Consult Request Form – Completed by DVM Included ( Diet History Form – Completed by owner Included ( Complete Blood Count Included ( Serum Chemistry Panel (inc. T4 if indicated) Included ( Urinalysis Included ( Other relevant medical records as necessary (UPC & BP for pets with CKD, biopsy and imaging results for pets with gastrointestinal or hepatic disease, etc.) Included ( **********Please ensure all labwork is current (within the last 6 months)********** Reason for request: (Please check one or more) ( Balance current home-cooked diet (Please attach a list of ingredients with amounts fed daily) ( Formulate home-cooked diet, because no commercial diet available to meet pet’s needs ( Pet finds commercial diets unpalatable ( Other, please specify: Please note if the request is urgent (additional fee will apply) May we contact the owner directly with questions if needed? ( Yes ( No Owner name: Pet name: Species: Age: Breed: Sex: M, MC, F, FS (circle one) Muscle Condition Score: Normal, Mild loss, Moderate loss, Severe loss (circle one) Body Condition Score (9 point scale): (Dogs: 4 to 5 is ideal; Cats: 5 is ideal) Body weight: Current: Ideal: (Please indicate kg or lb) Current medical problems: (Attach additional sheet if necessary) Does the pet have a good appetite? Typically: ( Yes ( No Currently: ( Yes ( No Has the pet been weight-stable? Historically: ( Yes ( No Currently: ( Yes ( No Previous medical history: (Please include dates) Other considerations: (Attach additional sheet if necessary) Current medications: (Attach additional sheet if necessary) Please read the FAQ and review the recipe template on our website prior to submitting this consult request. Thank you for your request. We will contact you with follow-up questions as needed. Customized home-cooked recipe formulation is $528, which is charged when the request is submitted ($260 for the Nutritional Assessment (nonrefundable) and $268 for the diet formulation). This includes up to 30 minutes of follow up. Additional follow-up is $124 per 30 minutes; this includes review of medical records as well as communications. If the initial diet formulation is not tolerated or palatable, one recipe reformulation can be provided at no charge if requested within 6 months of the initial formulation. Other diet reformulations and additional recipes are $336 each if requested within 6 months of the initial formulation. Calorie adjustments are always provided at no charge. Prices are current as of January 2026, but are subject to change. An invoice will be automatically emailed directly to your clinic by the VMTH Cashier’s Office. If your clinic wishes to opt out of paperless billing and receive a printed statement or invoice, please reach out to our billing team at HYPERLINK "mailto:vmcbilling@ucdavis.edu" \t "_blank" vmcbilling@ucdavis.edu. Please do not send payment prior to receiving the invoice.

FAQs

申请营养咨询需要提交哪些资料？

需勾选并提供：由DVM填写的申请表、由主人完成的饮食史表、CBC、血清生化（如适用含T4）、尿检，以及根据病情需要的其他医疗记录。

化验结果需要满足多长的时效要求？

所有实验室检查需保持当前状态，需在过去6个月内完成。

如需追加随访或配方调整，费用如何计算？

追加随访按每30分钟124美元计费，包含病历审核与沟通。若初次配方在6个月内不耐受或不易接受，可在无额外费用下提供一次复配；其他复配与额外食谱按每份336美元计费。

是否可以在需要时直接联系宠物主人？

申请表中会询问是否允许直接联系；根据勾选结果提供后续提问与沟通方式。

Sep 1, 2026

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