Nutritional Consultation Request Form Client InformationClient’s Name First Last Primary Cell Phone Number(Required)Email(Required) Pet InformationPet's Name Breed BirthdateAge Current Diet - check all that apply :Please include the brand name. Home cooked Raw Canned Dehydrated Freeze-dried Dry/Kibble Home cooked Raw Canned Dehydrated Freeze-dried Dry/Kibble Supplements(Please list all supplements given daily.)What concerns do you have with your pets’ diet?Quality of ingredients, current/past recalls, AAFCO approved, calories, etc.Health ConcernsFor example: itchy skin, licking paws, digestive issues, anal gland concerns, etc.Current BehaviorFor example: anxiety, excessive thirst, fatigue, pacing, excessive panting, etc.Please explain your desired GOAL / OUTCOME for this nutrition consultation:Nutritional Consultation Client ConsentI am requesting a consultation with Lori Wells-Bauer, a Nutritional Counselor, to discuss available nutrition and supplement options for my pet. The consultation may include discussing commercial diet options, prescription diets, home cooked meals, dehydrated meals, freeze-dried meals, RAW diets, and supplements. I understand Lori is a certified Nutritional Counselor with an extensive background and education in Integrative Veterinary Nutrition and is skilled at creating, evaluating, and ensuring balanced diets for pets. I understand Lori is not a licensed Veterinarian therefore is unable to make a diagnosis or prognosis for my pet. Further, I understand Nevada Veterinary Board Medical laws require my pet to be evaluated within 12 months of my initial consultation with Lori by a licensed Veterinarian. If I am not an established patient of Mountain View Animal Hospital and Holistic Pet Care, I understand my primary veterinarian must submit all Pertinent Medical Records and a Veterinarian Referral Form before I may be scheduled.I understand that the information I receive during my nutritional consultation is not intended or implied to be a substitute for professional veterinarian advice, diagnosis, or treatment. Clients are advised to discuss the information provided by Lori, including any written diet and/or supplement plans, with their primary veterinarian for possible changes necessary based on their current healthcare needs. In addition, a recheck with your primary veterinarian may be required in some situations before follow-up consultations with Lori can be performed. Pets must maintain an annual evaluation with their primary veterinarian to receive future nutritional advice. It is suggested that documentation from your veterinarian regarding major updates / changes in health status for your pet be forwarded to Lori and a follow up consultation should be made.Important: I, the client, understand that all Nutritional Consultations are performed via Teleconsultation (phone) only. If I do not answer or return Lori's phone call within 10 minutes of the scheduled time, I understand this will forfeit my consultation and I will need to be rescheduled. In this scenario, with respect to my and the Nutritional Counselors time, I understand I will be required to pre-pay for my pets next consultation which will be non-refundable. I understand the Nutritional Counselor, Lori, will call from a (530) area code phone number. I understand and agree to discuss one pet per appointment. If you have any questions or concerns, please call 775-853-6900 and ask to speak to our Holistic Team. We look forward to helping your pet live a longer, healthier life! SignatureDate MM slash DD slash YYYY
