Telemedicine Consultation Telemedicine Consent Form Consent FormPlease 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 915-755-2231Owners 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*Zoom Mobile Apps