Owner's Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Brief Description of Your Pet's Problem *

Pet's Name *

Breed *

Color/Markings *

Age (in weeks, months, years) *

Sex *

Male
Neutered Male
Female
Spayed Female

By checking this box, I am confirming that I am of legal age and responsible for the pet described above. I understand that I will be having a telemedicine consult with an agent of Tell Tail Veterinary Inc. The veterinarian-client-patient relationship (VCPR) is the basis for interaction among veterinarians, their clients, and their patients and is critical to the health of animals. VCPR is being established by a California-licensed veterinarian to a patient within California. *

I have read, understand, and agree

As with any online health service, there are potential risks associated with its use. When using this service, you understand these additional risks of telemedicine and waive any liability to Tell Tail Veterinary Urgent Care and its Veterinarians and employees. These risks include but may not be limited to: Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate health care decision-making. Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties. Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information. Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings. Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Veterinarian or the client. *

I have read, understand, and agree

Delays in evaluation or treatment could occur due to failures of the electronic equipment or clinic staffing lack of access to all of your health records may result in adverse drug interactions, allergic reactions, or other judgment errors; an incomplete or inaccurate diagnosis of pet. *

I have read, understand, and agree

I understand I may be required to schedule an in-hospital visit if it is felt that the information obtained via telemedicine was not sufficient to make a diagnosis. *

I have read, understand, and agree

If your pet is experiencing an emergency, you should visit an emergency animal hospital immediately. TELEMEDICINE will not be used for an EMERGENCY condition. *

I have read, understand, and agree

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, but no results can be guaranteed or assured. Withdrawal of consent may occur at any time and must be submitted by email or written communication to the Veterinarian. *

I have read, understand, and agree

Telemedicine prescriptions have limitations. A virtual VCPR diagnosis is limited to no more than 14 days of antibiotics and no controlled substances can be prescribed. *

I have read, understand, and agree

Best phone number to contact you during the time of the appointment *

Best email to send video link to *

Signature *

Clear Signature

Today's Date *

Telemedicine Consent Form

Telemedicine Consent Form

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