Telemedicine Consultation

Telemedicine Consent Form

Consent Form

• Please complete the following form to request a Telemedicine Consultation/Exam for your pet. Please also note that availability will vary. Thank you!
• Have you spoken to a staff member regarding Telemedicine?*
  • Yes, I have spoken to a staff member
  • No, I have NOT spoken staff member (Please Call 915-755-2231 before continuing this form)
  A staff member should have found your existing account on our system and you are ready to begin the consultation after answering a few questions. If you have not yet spoken to a member of staff please call us at 915-755-2231
• Owners Name: First and Last*
• Pet's Name:*
• Phone Number:*
• Email Address:*
• Today's Date:*
• I understand the following:*
  • The Telemedicine Consultation is to assess my pet(s) medical condition to the best of the Veterinarians ability via video and audio
  • The Consultation will be performed via two-way video and audio using the ZOOM APP.
  • If necessary the two-way communication might be viewed by someone other than the Veterinarian
  • Telemedicine will only allow the Veterinarian and or other health provider the ability to see the area of concern in question.
  • Telemedicine does not give the clinician any other senses such as touch or smell; and it may not be equal to a face-to-face visit. ( This will limit the ability to listen to lungs and heart)
  • I will be able to ask questions regarding my pet(s) condition
  • I may ask to stop the video conference at any time if need be.
  • I understand there might be technical issues using this service like audio, video or connections quality.
  • I understand that prior to beginning the Telemedicine consultation I will need to pay the fee of $40.00 for the consultation.
  • I am aware that my pet might have to be taken to the facility for additional testing or treatment at an additional fee for service.
• Please upload any relevant photo or video of your pets condition. Max 3 photos, videos or combination.
• Please write a brief description of your pets medical issues:
• I, the owner of the patient do hereby understand and state that I agree to the above consents:*
  • I agree
  • I decline
• Electronic Signature: By entering my FULL NAME*
  I certify that this form has been reviewed by me. I have read it and understood all aspects of this form. I understand and agree to its contents. I agree to participate in the Telemedicine examination. I authorize Northeast Veterinary Clinic and its Veterinarians, Technicians , and other staff members involved to perform procedures that may be necessary for my pet(s) current medical needs.
• Today's Date*

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