Telemedicine Authorization Form -

Client Information

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email

Phone

Patient Information

Name of pet

Species

Breed

Color

DOB

Owner Consent*

√ I certify I am the legal owner/authorized agent for the owner of the companion animal described above and give Four Paws Veterinary Wellness, and any authorized agents, staff, or representatives full and complete authority to use telemedicine to evaluate, diagnose and treat the above-described companion animal. I agree that Four Paws Veterinary Wellness, and any authorized agents, staff, or representatives shall not be liable for any direct, indirect, or consequential damages resulting from such telemedicine

Telemedicine Limitations Agreement*

√ I understand there are limitations with telemedicine and that an in-personal physical examination may be recommended.

Medication Agreement*

√ I understand that there are some circumstances in which we are not able to prescribe medications for telemedicine patients without a physical examination.

Pet Present During Telemedicine Appointment*

√ I understand that my pet must be present during the telemedicine consultation.

Telemedicine Technical Difficulties Agreement*

√ I understand that technical difficulties may occur before or during the telemedicine session and my pet’s appointment may not start or end as intended or may be interrupted if there are technical difficulties.

Telemedicine Disclaimer*

√ I understand that telemedicine is NOT an emergency service and in the event of an emergency, I will contact my primary care veterinarian or an emergency veterinary service.

Signature*

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Typed Signature*

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Date*

File

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Phone

This field is for validation purposes and should be left unchanged.

Telemedicine Authorization Form

Client Information

Patient Information

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