Telehealth Consent Form
Consultation Details
- Date of consultation
- Time of consultation
- Consultation method
- Consultation fee ($)
- Animal's location during the consultation
Client's Details
- First name
- Last name
- Address
- Phone
Patient's Details
- Name
- DOB (age)
- Microchip
- Weight (kg)
- Gender
- Species
- Breed
- Regular vet clinic
About Telehealth
A telehealth consultation is a remote consultation. The veterinarian cannot physically examine your animal, so what can be assessed, diagnosed, treated or prescribed remotely is limited, and depends on the rules of the place where you and the veterinarian are located and on whether the veterinarian has an existing relationship with your animal. You may be advised that an in-person examination is required. Telehealth is not suitable for emergencies: if your animal is in an emergency, contact or attend a veterinary clinic immediately.
- I consent to the consultation being recorded for the clinical record
- Share the consultation summary with my regular vet clinic
Consent
I understand the nature and limits of a telehealth consultation as described above, including that no physical examination is possible, that no diagnosis or treatment can be guaranteed, that prescribing may not be possible depending on local rules and the veterinarian's prior relationship with my animal, and that I may be directed to an in-person examination. I confirm that the information and images or video I provide are accurate and relate to the animal described on this form. I understand that technology can fail and that an interrupted consultation will be resumed or rebooked. I agree to pay the consultation fee stated, which covers the veterinarian's time and advice whether or not a diagnosis or prescription results. I confirm that I am over the age of 18 years and am the owner, or an authorised agent of the owner, of this animal.
- Owner / agent name
- Date signed
Owner / agent signature
- Consulting veterinarian
- Registration number
Veterinarian signature