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Nutrition Referral Form

 

  • Before a teleconsultation with the RBVH Clinical Nutrition Service can be performed, we must receive the:
    • Nutrition Referral Form (complete by the referring veterinarian)
    • Pertinent medical records
    • A complete physical examination and lab work including CBC, serum biochemistry, and urinalysis must be performed within the last 6 months to proceed with a remote nutrition consultation. Your client has been instructed to schedule an appointment if this has not been performed. If there are barriers to submitting this lab work, the referring veterinarian may call or email Dr. Cline to discuss (nutrition@rbvh.net or 732-747-3636).
    • Diet History Form (completed by the pet owner)

    The above items MUST be received by 7 business days PRIOR to the scheduled appointment. The RBVH Clinical Nutrition Service reserves the right to cancel the pet's appointment if the above items have not been received in this time period.

  • Note: Submitting a Nutrition Referral Form to the RBVH Clinical Nutrition Service signifies the listed referring veterinarian has an established veterinary-client-patient relationship (VCPR) for this patient and authorizes members of the RBVH Clinical Nutrition Service to perform remote consulting directly with the patient’s owner.

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    *within last 6 months
  • (Please send a complete copy of results and reference intervals from any lab(s) to ensure proper patient identification. All requests must include copies required lab work including a CBC, serum biochemistry, and urinalysis from the last 6 months. Your client has been instructed to schedule an appointment if this has not been performed. If there are barriers to submitting this lab work, the referring veterinarian may call or email Dr. Cline to discuss (nutrition@rbvh.net or 732-747-3636).
















    *including feeding tube and/or parenteral nutrition plans
  • (i.e. diagnostic results, physical exam notes, and summary sheets for at least 6-12 months prior to the consult request.)
  • (If complex/ongoing condition, please send medical records showing meds/treatment.)

























































  • Note: Submitting a Nutrition Referral Form to the RBVH Clinical Nutrition Service signifies the listed referring veterinarian has an established veterinary-client-patient relationship (VCPR) for this patient and authorizes members of the RBVH Clinical Nutrition Service to perform remote consulting directly with the patient’s owner.






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