TeleMed Consult

Medical History Questionnaire

Medical history

Please fill in the health questions below so we can be sure to cover everything while your pet is here. This also helps us keep your pet's record up to date between visits!
Please check all that apply
Please check all that apply

Please list any Medications, Supplements your pet is Currently Taking

Remember Heartworm Preventives, Flea/Tick Protection, Vitamins and Natural supplements

Telemedicine Consult Limitations

I Understand that: This Telehealth consult will not be as thorough as an exam in person. There is a fee of $25 upon completion of the Telehealth consult. This fee is not refundable. However, If it is determined, during this consult, that my pet cannot be sufficiently treated without an exam in-clinic, the amount of the Telemedicine consult fee will be applied to the in-clinic exam when it occurs. (If my pet is not presented in-clinic for the issue after recommendation by the veterinarian, no credit or refund will be provided.) If this consult is interrupted due to technological difficulties, it will be restarted. Other team members may be within hearing of this consultation during video Ccnferencing. These people will all maintain confidentiality of any information overheard. However, if, at any time, you would like more privacy, we will accommodate. For Emergency consultations where our doctors do not have a Veterinary-Client-Patient Relationship, we will forward records of this consult to your regular veterinarian. If you have any additional questions about the Telemedicine consult process, please call our office at 520 886-1125


By typing my name below I agree to the terms of the Telelmedicine Consult Limitations described above.