Tele-Medicine Consent Form
Telemedicine Consultation Consent Form -Available during the COVID-19 Pandemic ONLY
To participate in this telemedicine consultation please read each paragraph and initial the paragraph to indicate your understanding and acceptance. Please sign this form, scan or photograph the form, and return it by email to [email protected]
This telemedicine consultation is only available to those that are unable to leave their homes to bring their pet to the veterinary hospital for the following reasons:
1) You are in quarantine because you have traveled to another country.
2) You are awaiting results of your COVID-19 screening.
3) You are under quarantine because you have tested positive on COVID-19 screening.
Initial ________________
This telemedicine consultation is NOT available to the general public who wish to self- quarantine.
Initial _______________
Telemedicine consultations are limited in their diagnostic ability. It does not and cannot replace a full physical examination performed by a licensed veterinarian. The goal of the consultation is to provide guidance and triage in situations where the owner and pet cannot leave their homes. Without a physical exam and appropriate diagnostic testing there is a risk of missing a diagnosis.
Initial ________________
I, _________________________________ (Please print your name), would like to proceed with a telemedicine consultation and understand the limitations of such a consultation.
Signature ____________________________
To participate in this telemedicine consultation please read each paragraph and initial the paragraph to indicate your understanding and acceptance. Please sign this form, scan or photograph the form, and return it by email to [email protected]
This telemedicine consultation is only available to those that are unable to leave their homes to bring their pet to the veterinary hospital for the following reasons:
1) You are in quarantine because you have traveled to another country.
2) You are awaiting results of your COVID-19 screening.
3) You are under quarantine because you have tested positive on COVID-19 screening.
Initial ________________
This telemedicine consultation is NOT available to the general public who wish to self- quarantine.
Initial _______________
Telemedicine consultations are limited in their diagnostic ability. It does not and cannot replace a full physical examination performed by a licensed veterinarian. The goal of the consultation is to provide guidance and triage in situations where the owner and pet cannot leave their homes. Without a physical exam and appropriate diagnostic testing there is a risk of missing a diagnosis.
Initial ________________
I, _________________________________ (Please print your name), would like to proceed with a telemedicine consultation and understand the limitations of such a consultation.
Signature ____________________________
