Telemed Consent Form

Complete the telemed consent form to get ready for your pet’s virtual consultation.

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Telemed Consent Form

Fill out the telemed consent form online to streamline your pet’s telemedicine visit.

Pet's Name *

Owner's Full Name *

First

Last

Owner's Phone number

Since Telemed appointments are less thorough than an in-person examination, your doctor may decide, during the consult, that your pet needs an in-person physical examination. In that case, the cost of the telemedicine consult will be applied to the in-person exam fee. *

I agree to the terms above

Veterinarians are limited ot the amount and type of presciption medications that can be prescribed based solely on a diagnosis made by telemed examinations. *

I agree to the terms above

As Per AZ Law: Prescriptions may only be issued for up to 14 days. May be renewed 1 time for 14 days with an additional telemed consult. Further Renewals require an in-person visit. Some medicaitons may be available at a human pharmacy. Controlled substances cannot be prescribed without an in-person patient exam.

I case your telemed consult is interrupted, what is a good alternate means of getting back in touch with you? *

There may be other staff members present during the consultation other than my pet's veterinarian. If you are uncomfortable at any time, you may ask non-medical personnel to leave the telemedicine examination room: and or terminate the consultation at any time. *

I agree to the terms above

There is a Telemed Consult fee of $ _ We accept that payment prior to the appointment. *

I agree to the terms above

are to applied

By typing my name below I indicate my understanding of the Telemedicine Consult Terms Above.

Name *

First

Last

Date Signed

Telemed Consent Form

Telemed Consent Form

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