Please Note: We will be closed on Wednesday, April 22nd, for an off-site team training. We will return to regular business hours on Thursday, April 23rd.

Telemedicine Authorization

Authorize telemedicine appointments

Filling out this form indicates you agree to the telemedicine terms. If you’re in need of immediate assistance, please contact us directly at 815-229-1234.

Name *

First

Last

Secondary Name

First

Last

Email *

Cell Phone *

Pet's Name *

I hereby authorize the veterinarian to provide a consultation regarding my above named pet via telecommunication. This applies to the assessment of my pets health, behavior, environment, and/or welfare, including phone, email, messaging, PetDesk App, and/or video recording of video chat sessions. I understand that photos, messages and videos submitted to Perryville Pet Hospital become part of a legal medical record to be used for assessment, and I allow use of this media to other professionals for consultation or educational purposes. I understand that telemedicine is not equivalent to a hands on physical exam and in-person assessment, where images/videos and my own personal description may alter the true condition of my pet. I understand that a hand on exam and in-hospital diagnostic testing may still be necessary to provide a proper diagnosis and treatment plan. *

I have read and agree to these terms.

A per pet fee of $60 for new consultations or a $45 fee for follow-up consults are non-refundable and required to secure your appointment. Consult fees includes any type of communication with veterinary technician and/or veterinarian for upto 20 minutes. I understand that this consult fee would apply to an in-hospital exam within the following 2 business days only if the visit is for the same condition/concerns assessed in the telemed consultation. Any unpaid balance over 60 days may be send to collections, with all fees for collection services added to the balance for services. I assume responsibility for all charges for this and any future consultations. Telecommunication with the veterinary staff as well as hours of availability are determined by the veterinary staff. *

I have read and agree to these terms.

Date *

Name

Telemedicine Authorization

Authorize telemedicine appointments

Filling out this form indicates you agree to the telemedicine terms. If you’re in need of immediate assistance, please contact us directly at 815-229-1234.

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