Name* Phone*Date MM slash DD slash YYYY Email* Pet InformationNameDOB or AgeBreedSex Telemedicine/Tele-triage is the delivery of health care services using email, text messaging, interactive audio or video technology, where the pet and the veterinary professional are not in the same physical location. Acknowledgment* I am confirming that I am of legal age and responsible for the pet described above. Confirmation fo VCPR* Prior to using these services, you understand that the veterinarian must have a valid veterinarian-client-patient-relationship (VCPR) to perform telemedicine. If you are only seeking veterinary advice, and there is not a valid VCPR established with the veterinarian, you will not be receiving a diagnosis, treatment, prognosis, or prescription medication. Consent* I understand that veterinarians rely on the physical examination of an animal through the use of palpation (touch), sight, listening, and smell in order to determine the best medical advise and diagnosis. They also use the client's history of the pet and the symptoms they observed combined with the physical exam to determine the pet's health and needs. Since telemedicine/tele-triage cannot provide both of these requirements, it is understood that this consult is not entirely complete and further examinations, diagnostics, and treatments of your pet with your veterinarian may be required at the veterinary hospital with there appropriate charges. If your pet is experiencing an emergency, you should visit an emergency animal hospital immediately. Telemedicine will not be used for an Emergency condition. By accepting these Terms of Use, you acknowledge that you understand and agree with the following: you may expect the anticipated benefits from the use of telemedicine/tele-triage, but that no results can be guaranteed or assured. You understand if you are seeking a DIAGNOSIS, TREATMENT, OR PRESCRIPTION MEDICATION by Virtual Consultation, your pet must have been seen by the veterinarian within the previous 6 months to the scheduled consult. SignatureCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
