Telemedicine Consent

    Client's Name*

    Email*

    Pet's Name*

    Phone*

    Telemedicine:

    Terms and Conditions:

    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?*