Telemedicine Consent

Client's Name*

Email*

Pet's Name*

Phone*

Telemedicine:

I have read and understand: HousePaws In Home Vet is able to offer scheduled rechecks, behavior consultations, and medical triage style appointments via telemedicine for existing patients that have had a physical exam performed by Dr. Laura McMahan within the last 12 months. Telemedicine appointments are conducted through the use of a computer, smartphone or tablet and allows our veterinarian to see your pet and perform a visual exam during the appointment as needed.*

Terms and Conditions:

I have read and understand: I, the undersigned, authorize HousePaws and each veterinary staff member, including Dr. Laura McMahan, 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 HousePaws 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 HousePaws, its officers, directors, employees, shareholders, agents, successors, and assigns, and Dr. Laura McMahan (collectively, the “HousePaws Team”) from and against any and all loss, damage, claim, or cause of action, whatsoever. I give permission for HousePaws and the HousePaws 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 and understand: I AGREE THAT HOUSEPAWS AND THE HOUSEPAWS 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.*

I also understand that charges will be paid in full at the time of the appointment per the following Fee Schedule: Initial Telemedicine Consultation $75*

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

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?*