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.

Signature *

Clear Signature

Date *

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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