Nutritional Consultation Request Form Date MM slash DD slash YYYY Name First Last PhoneEmail Pet's Name Species Breed Gender AgeSpayed or neutered Yes No Current Diet - check all that apply Home cooking Raw Canned Dehydrated Freeze-dried Dry/Kibble Please list brand names in current diet or ingredients in home cookingDoes your pet take supplements? Please list them hereAre you happy with your pet's diet? Do you have any concerns like quality of ingredients, current or past recalls, AAFCO approved, etc.Do you have any health concerns like itchy skin, licking paws, digestive issues, anal gland concerns, etc.Current behavior like anxiety, excessive thirst, fatigue, pacing, excessive panting, etc.What is your greatest concern for your pet in relation to their diet?Please explain your desired goal for this nutrition consultationAll services are offered via phone/email. Lori will call you the day of your appointment, please make sure we have a current phone number in your account. A notepad or paper is helpful for note taking.Which service would you like to schedule Nutrition Consult - $57 - 30 mins Supplement Consult - $77 - 30 mins Diet & Supplement Consult - $102 - 60 mins Weight Loss Program - $152 - 30 mins Fully Balanced Home Cooked Diet - $202 - 60 mins Critical Care Nutrition Consult - $252 - 60 mins Recipe generation may be added on to any service Fully balanced - $100 Partial home cooked - $50 Recipe adjustment - $25 For additional information about services see our downloadable form“Let food be thy medicine!” Lori looks forward to working with you and your pet(s). 1 appointment per pet, pet’s must be seen by one of our veterinarians within an 18 month period to sign up for a consultation. If you have additional questions please don’t hesitate to call our Holistic Center today: 775-853-6900 Payments can be collected the day of via credit card number.