Consultation Request Form for Tufts Clients

In order for us to make the best recommendations for your pet, the following items are requested. All laboratory tests should be dated within the last 6 months unless an exception is granted. For sick pets, more recent lab work may be needed. Please call if you have any questions.
- Veterinarian Nutrition Consult Request Form (required for phone consults and veterinarian consults)
- Diet history form (this form - required for all consults)
- Complete blood count, biochemistry profile and urinalysis (all consults)
- Additional relevant diagnostics (e.g., urine culture, T4, ultrasound reports)
- Last year’s medical records or as appropriate (all consults)
We will send you this information in your confirmation email as well
Tufts Case Number
If applicable
Which service(s) did your pet see?*
Select one or more services that saw your pet at Tufts
- Behavior
- Cardiology
- Dermatology
- Emergency and Critical Care
- Internal Medicine
- Neurology and Neurosurgery
- Oncology
- Ophthalmology
- Orthopedic Surgery
- Soft Tissue Surgery
- Other
Do you know the name of the doctor(s) you saw at Tufts?*
- Yes
- No
Name(s) of doctor(s) seen at Tufts*
Have you ever consulted with a veterinary nutritionist before?*
For this or any other pet?
- Yes
- No
Did you consult with a nutritionist at Cummings Veterinary Medical Center?*
- Yes
- No
What is the name of the veterinary nutritionist you saw?*
Please provide the name of the doctor or clinic with which you consulted

Primary Owner Information
Provide the contact details for the main point of contact for this pet.
Client Name*
First Last
Client Address*
Street Address Address Line 2 City State ZIP Code
Client Phone*
Client Email*
Is there a co-owner of this pet you would like to include?*
- Yes
- No
Co-Owner Name and Information
List the name and information for this pet's co-owner if applicable
Co-owner Name
First Last
- Co-owner address is the same as the primary owner
Co-owner Address
Street Address Address Line 2 City State ZIP Code
Co-owner Phone
Co-owner Email

Reasons and Goals for the Consultation
Reason and goals for the consultation*

Your Pet's Current Food

Please list below the product names, flavors (if applicable) and amounts of ALL foods, treats, snacks, and any other foods that your pet is currently eating. This description should provide enough detail that we could go to the store and purchase the exact same food. It should include “people foods” given as treats or at the table or as part of a homemade diet. For homemade diets and human foods, please include weights (grams or ounces) or common measures (cups, tablespoons) of each ingredient fed.

Examples:

Food or Treats	Type	Amount per meal	How often?	Fed since?
Purina Dog Chow Complete Adult with Real Beef	dry	1 ½ cups	2x/day	Jan. 2004
90% lean hamburger	pan-fried	3 oz	1x/week	May 2009
Milk Bone medium	dry	2	3/day	Aug. 2008

Click the PLUS (+) at the end of the row to add additional rows as needed.

Foods and Treats*
Food or Treat Type Amount per meal How often? Fed Since
Do you give any dietary supplements to your pet?*
For example: vitamins, glucosamine, fatty acids, or any other supplements
- Yes
- No
Supplements*
List product names, amount and frequency.

Click the PLUS (+) at the end of the row to add additional rows as needed.
Product Name Amount Given Frequency Given
Do you give any medications to your pet?*
- Yes
- No
Medications*
List the drugs and dosages of each medication you give your pet.

Click the PLUS (+) at the end of the row to add additional rows as needed.
Drug Dosage
Do you use food to administer medications?*
This includes Pill Pockets, cheese, bread, peanut butter, etc.
- Yes
- No
List Foods to Administer Medications*
Tell us what kind(s), how much and how often you use food to administer medications to your pet.

Click the PLUS (+) at the end of the row to add additional rows as needed.
Food Item Amount How often?
Past Commercial Diets
Optional: A listing of all other commercial diets you are not currently feeding but have fed to your pet in the past is helpful to us. Please include diet name, approximate dates, and reasons for discontinuing.

Click the PLUS (+) at the end of the row to add additional rows as needed.

Diet Name Approximate Dates Reason for Discontinuing

Your Veterinarian(s)
Primary Veterinarian's Name*
If you are using more than one veterinarian, this should be the vet that you see the most for your pet’s current health concerns or for routine wellness if your pet is healthy. This will be the veterinarian that is our main point of contact regarding your pet’s health and should be the veterinarian to fill out our Veterinarian Consult Request Form. If you provide an email address for this veterinarian, we will send them a request to fill out the Consult Request Form.
First Last
Primary Veterinarian's Clinic*
Clinic Name Street Address City State ZIP Code
Primary Veterinarian's Phone*
Primary Veterinarian's Fax
Primary Veterinarian's Email
Additional Veterinarian's
Please list your pet’s additional veterinarians and their contact info below.

Please tell us what role each veterinarian has in your pet’s care – is this vet an internal medicine specialist or an oncologist, or does this vet do acupuncture or rehabilitation only?

It is not necessary to list veterinarians that your pet has only seen once unless it was for a significant illness that could relate to your pet’s nutritional plan – for instance, if your pet was hospitalized at an emergency clinic for an illness or had surgery somewhere other than your normal veterinarians’ hospitals.

Please also indicate whether each of these veterinarians has a continuing role in your pet’s care and should be kept up to date on your pet’s nutrition plan.

Click the PLUS (+) at the end of the row to add additional rows as needed.
Name Clinic's Name Clinic Phone Clinic Fax Clinic or Veterinarian's Email Role (e.g., oncologist) Keep this vet updated? (yes/no)

Medical Records
In order for us to make the best recommendations for your pet, the following items are requested. All laboratory tests should be dated within the last 6 months unless an exception is granted. For sick pets, more recent lab work may be needed. Please call 508-887-4696 if you have any questions.
- Complete blood count, biochemistry profile and urinalysis (all consults)
- Additional relevant diagnostics (e.g., urine culture, T4, ultrasound reports)
- Last year’s medical records or as appropriate (all consults)
Do you have electronic copies of any of these medical records that you can upload now?*
- Yes
- No
Medical Records Upload*
Choose the files to upload here. You may upload up to 5 files at one time.
Drop files here or

Max. file size: 155 MB, Max. files: 3.