Consultation Request Form

Additional Medical Conditions

Let us know what (if any) additional medical conditions your pet may have

Bladder Disease (e.g., stones, infection)
Cardiac (heart)
Cancer
Digestive Issues (i.e., stomach or intestinal problems)
Diabetes
Kidney Disease
Liver Issues
Obesity/overweight
Orthopedic
Respiratory (e.g., lung or breathing issues)
Pancreas
Skin issues
Other

Other condition(s)*

You indicated “Other” in your selection of medical conditions. Please briefly describe the condition (for example, behavior, Cushings disease, neurological disease, thyroid disease, eye problems, infectious disease, lung problems, etc.)

Are you requesting a home-cooked diet?*

Yes
No

Home-cooked Diets

Please read the following before proceeding. After reading this, we will ask you a series of questions to which you must agree in order to be referred for a home-cooked diet with our service.

Before you request a consultation, please identify the ingredients that you are willing to cook and that you know your pet will eat. If you have not tried a home-cooked diet before, please test ingredients (one protein, one carbohydrate, and one fat) with your pet to ensure they will eat them prior to requesting a consultation with the Nutrition Service. Swapping or rotating ingredients will unbalance your pet’s diet and is not recommended.

Please see our website for more details.

After reading the above, are you still interested in a home-cooked diet for your pet?*

Yes
No

Additional required information about your pet and home-cooked diets

More information about your pet*

Please check all of the statements below that are TRUE

My pet is less than a year old
My pet is a cat
My pet has bladder stones
I cannot feed my pet just one protein, one carb and one fat
None of the above statements is true for my pet

Agree to our terms for home-cooked diets*

In order to provide you with a home-cooked diet for your pet, we ask that you agree to our terms of service.

First, we use supplements recommended by Board Certified Veterinary NutritionistsTM. Will you use the supplements we recommend?
Second, home-cooked diet formulations start at $437 including the consultation. Are you willing to pay for this service?

Yes, I agree to use the supplements recommended and pay the fee
No, I do not agree to use the supplements recommended or pay the fee

Why do you want a home-cooked diet for your pet?*

Briefly tell us why you want or are interested in a home-cooked diet for your pet?

More Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Pet's Name*

Pet's Species*

Pet's Breed*

Pet's Weight*

Please indicate lb or kg

Pet's Age*

Pet's Sex*

Is your pet spayed or neutered?*

Reasons and Goals for this Consultation*

Briefly tell us why you are requesting an appointment or consultation with the Clinical Nutrition Service at Tufts. You are limited to fewer than 1500 characters.