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Telehealth Consent Form

A free fillable telehealth consultation consent for veterinary use. Record the consult details and elections, sign on screen, then print or save as a PDF. Patient and owner details are never stored or sent anywhere.

Consultation

Consultation Details

(state / country - this can affect what the veterinarian is permitted to do)

Client

Client's Details

Patient

Patient's Details

(if any)

Telehealth

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

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 signature
Veterinarian signature
Preview

Telehealth Consent Form

Live preview · prints exactly like this

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
Email

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

Built by Dr Duncan Houston for Ask A Vet · askavet.com

Nothing typed into this form is sent to or stored by askavet.com. All data stays in your browser and leaves only in the PDF or printout you create. Telehealth and remote prescribing rules differ significantly by jurisdiction. Check the telemedicine guidance of your local veterinary regulator before use.

Dr Duncan Houston
About the author

Dr Duncan Houston · BVSc, Veterinarian

Emergency careGeneral practiceMobile vet careFounder, ASK A VET™

Dr Duncan Houston is an Australian veterinarian with experience in emergency, general-practice and mobile veterinary care. He is the founder of ASK A VET™. This guide is educational and is not a substitute for hands-on veterinary care.