Telemedicine Consultation History and Consent Form

Thank you for choosing Healing Paws Veterinary Care. Please fill out the following form as thoroughly as possible so we can better serve your pet. If you have any questions, please give us a call. We look forward to seeing you and your pet!

Client's Name *

First

Last

Email *

Pet's Name *

Phone *

Telemedicine:

Healing Paws Veterinary Care, Inc. (“Healing Paws”) is able to offer scheduled rechecks, behavior consultations, and medical triage style appointments via telemedicine. Telemedicine appointments are conducted through the use of a computer, smartphone or tablet and allows our veterinarians to see your pet and perform a visual exam during the appointment. Please be sure your pet is with you during the entire appointment. *

I have read and understand

During the course of the appointment, the veterinarian may decide that your pet needs an in-person physical examination, treatment, and/or diagnostic testing. Should an in-person appointment occur within a reasonable amount of time thereafter as determined by Healing Paws, a $25 credit will be applied to your invoice at the in-person appointment. *

I have read and understand

Terms and Conditions

I, the undersigned, authorize Healing Paws and each veterinary staff member, including Dr. Tracy Sands, to examine, prescribe and treat my pet via teleconference. I understand that without physically examining my pet or performing diagnostic tests such as bloodwork or radiographs, the veterinarian may not have all of the information needed to provide a full and accurate diagnosis. I understand that the veterinarian is making the best recommendation possible without physically seeing the pet and I shall not hold the veterinarian or Healing Paws responsible if this diagnosis is inaccurate or if my pet does not improve with the recommended treatment. Except in the case of gross negligence, I hereby and forever waive any and all claims arising in any way out of the telemedicine services, and further agree to indemnify forever Healing Paws, its officers, directors, employees, shareholders, agents, successors, and assigns, and Dr. Tracy Sands (collectively, the “Healing Paws Team”) from and against any and all loss, damage, claim, or cause of action, whatsoever. I give permission for Healing Paws and the Healing Paws Team to discuss medical information via telephone, email, and online video conferencing, and to record the same. I understand that the laws that protect privacy and confidentiality of medical information also apply to telemedicine. I understand that no information obtained during my telemedicine appointment will be disclosed to third parties without my consent. *

I have read, understand, and authorize

I AGREE THAT HEALING PAWS AND THE HEALING PAWS TEAM SHALL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL, SPECIAL, OR CONSEQUENTIAL DAMAGES ARISING UNDER OR RELATED TO THIS AGREEMENT OR THE SERVICES PROVIDED HEREUNDER. IN ADDITION, HEALING PAWS’ AND THE HEALING PAWS TEAM’S LIABILITY FOR DIRECT DAMAGES UNDER OR RELATED TO THIS AGREEMENT (WHETHER IN CONTRACT OR TORT) SHALL NOT, IN ANY EVENT, EXCEED THE COSTS OF HEALING PAWS EITHER FIXING THE DAMAGES OR COVERING THE COSTS OF ANOTHER VETERINARIAN FIXING THE DAMAGES AT THE EXPENSE AND IN THE SOLE DISCRETION OF HEALING PAWS. *

I have read, understand, and agree

I also understand that charges will be paid in full at the time of the appointment per the following Fee Schedule: Initial Telemedicine Consultation (up to 20 minutes) $64.64. Time spent in consultation beyond 20 minutes will be charged at an additional rate of $3.00 per minute. *

I have read, understand, and agree

BY SIGNING BELOW, YOU ACKNOWLEDGE, CONSENT AND AGREE TO THE TERMS, CONDITIONS AND STATEMENTS HEREIN. *

I have read and agree

Date *

Background Information for Telemedicine Consultation

Reason for consultation: Please describe your pet’s symptoms and your concerns. *

Has your pet experienced this problem before? If so, when and did it resolve completely? *

List your pet’s diet (all current food and treats, including brands and amount). *

List all current medications, supplements, and over the counter products your pet is receiving. *

Have you tried any home remedies for what is going on with your pet? If so, please describe. *

What, if anything, are you using monthly for your pet to prevent fleas, ticks and heartworm? *

Do you need any medications, supplements, or diet refilled today? *

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Telemedicine Consultation History and Consent Form

Telemedicine:

Terms and Conditions

Background Information for Telemedicine Consultation

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