Nutrition Referral Form

Please complete the online form and click the "Submit" button at the bottom of the page. You will receive a confirmation email message immediately after submitting your referral form. 

Please note: There seems to be a problem submitting the online referral form when using Internet Explorer (IE). Pease use another browser until the issue has been addressed.   

If you have any questions or problems completing this form, please contact
Fields marked with a red asterisk must be completed before submission.

Confirmation Email Address:?
Referring Veterinarian's Information
Reason for referral To refer client for an appointment at the VMC
To request a remote consultation (Please note: As of April 10, 2017, the VMC clinical nutrition service will no longer provide remote nutritional consultations for veterinarians treating patients outside the VMC)
Hospital name
Email address
Client Information
Client name
Postal code
Preferred phone Cell
Preferred #
Alternate phone Cell
Alternate #
Client email
If needed, may we directly contact the pet's owner with our questions? Yes
Patient Information
Service Small Animal
Large Animal
Patient name
(01 Jan 2014)
Gender M
Date and type of last vaccination
Reason for referral (check all that may apply) Commercial diet recommendation for a specific pet
Weight loss plan needed
Assisted feeding (tube feeding) recommendations and plan
Balance current home-cooked diet
Formulate home-cooked diet
If you chose "Formulate home-cooked diet," please choose any that apply Because no available commercial diet is known to meet the pet's needs
The pet finds available commercial diets unpalatable
Owner preference
Body condition score (9-point scale). Ideal for dogs: 4-5; ideal for cats: 5.
Current body weight (kg)
Ideal body weight (kg)
Is the pet's weight stable? Yes
If not, was the weight change unintended? Yes
Did the pet gain or lose weight? Gained
How much weight did the pet gain or lose?
When did the pet begin to lose/gain weight?
Over what time range has the weight gain/loss occurred (weeks, months, years)?
How would you describe the pet's current appetite? Normal
Severely anorexic
If the pet's appetite is abnormal, please describe (include duration in days/weeks)
Date of initial presentation for problem
(01 Jan 2014)
Patient history/findings
Current therapy/medications for condition
Previous therapy/medications for condition
Current and recently discontinued supplements
Other medical conditions or medications/therapy
Previous diets that were prescribed or tried. Please include reason for discontinuing.
Does this pet have adverse reactions to any foods? If yes, please specify.
As this pet's primary veterinarian, do you have any objections to the use of specific ingredients? If yes, please specify.
Laboratory Results
All labwork should be no older than six months old unless a specific exception has been granted (please call). Sick pets or those with chronic diseases should have more recent labwork.
These tests are required to proceed with a formal consult. Please mark all that are included. Complete blood count
Serum chemistry panel with electrolytes (T4 if indicated)
Other relevant medical records as needed/available. Please specify.
Laboratory Reports
If you are having difficulties attaching test document files through the online system below, please email the documents to In the email's subject line, include the animal's first and last name.
Lab reports Lab reports attached
Please return lab reports
Lab report #1
Lab report #2
Lab report #3
Medical Images Medical images attached
Please return medical images
Medical image #1
Medical image #2
Medical image #3
Diagnosis #1
Diagnosis #2
Diagnosis #3
Special concerns and/or considerations