Nutrition Counseling Please complete the form below in its entirety. Our counselors will review all of the information and respond within 1 week with recommendations and/or additional questions. If it is determined that you would like to conduct a one-on-one session with one of our counselors after you have received the recommendations you may request that during the communication process. Your Name: First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contact Information:Home PhoneMobile PhoneYour Email Veterinarian InformationVeterinarian NameVeterinarian NameHospital NameVeterinarian Phone#Dog's Information: (please complete separate forms for each pet)Pet's NameAgeBreedGender*MaleFemaleReproductive Status*Spayed/NeuteredIntactCurrent weight (please be as accurate as possible)Ideal Weight (please confirm with your veterinarian)Please check any symptoms that may apply to your dog: Itchy, red, moist or scabbed skin Increased scratching Itchy, runny eyes and/or tear stains Itchy back or base of tail (most commonly flea allergy) Itchy ears and ear infections Sneezing Vomiting Diarrhea Paw chewing/swollen paws Constant licking Change in appetite. Excessive thirst/increase in water consumption. Weight loss. Increased urination. Urinary tract infections. Additional info on any past or current health issuesIf there are any current health issues, has your dog seen a vet for a diagnosis? Describe in detail.*Does your dog have any allergies?YesNoUnsure/UnsureIf yes, were they diagnosed? Describe in detail.Does your pet have a history of seizures?*YesNoIf yes, were they diagnosed by a vet? Describe in detail.List all medications your dog is currently taking (if any) or has been taking recently, their dosage(s)? and frequency.Please describe in detail what brand and type/flavor of store bought food you currently feed your dog each day.Please describe in detail your pets feeding schedule (time, amount, etc.). Please be specific.Please describe any changes to your dog's diet history over the past 2 years.List any snacks you use including brand info, quantity given and frequency.Does your dog exhibit any senstivities to particular foods (often presented as inflammation in mouth area, tummy upset, redness around the mouth, vomiting, etc.)*YesNoIf yes, what food items?What kind of exercise does your dog get on a daily basis?Describe your dog's overall activity level.Tell us about any carbohydrate preferences you may have for pet.No PreferenceMay include grains and/or grain products (e.g. rice, oats)Only grains consistent with a gluten-free diet (e.g. rice, quinoa, millet)Grain free, using non-grain carb sources only (e.g. potatoes, sweet potatoes, split peas)Please list any diet restrictions you would like us to consider when determining our recommendations (ie. no pork, no beef, no wheat, etc.)List any items your dog refuses to eat.List any food items your dog is particularly fond of:* I certify that I understand that Mutts & Co. LLC is not providing medical care or medical advice for my pet. I understand that Mutts & Co. LLC is providing nutritional advice based on the information provided, and that it is my responsibility to discuss this advice with my veterinarian before proceeding with any changes to my pet’s diet. Mutts & Co. LLC is not providing advice that is intended to replace the advice of your veterinarian, but instead recommends that I take the advice they have given me to my veterinarian for review. The recommendations we are making are not meant to diagnose or cure any illnesses, and should be used under direction and supervision of your veterinarian. NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.