*2024_TeleHealth Consent Form

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Telehealth is the overarching term that encompasses all uses of technology to deliver health information, education or care remotely. Telehealth can be divided into categories based on who is involved in the communication.

Telemedicine
Telemedicine is a subcategory of telehealth that involves use of a tool to exchange medical information electronically from one site to another to improve a patient's clinical health status. Examples include using Skype or a mobile app to communicate with a client and visually observe the patient for a post-operative follow-up examination and discussion. Telemedicine is a tool of practice, not a separate discipline within the profession. The appropriate application of telemedicine can enhance animal care by facilitating communication, diagnostics, treatments, client education, scheduling, and other tasks. Practitioners must comply with laws and regulations in the state in which they are licensed to practice veterinary medicine. Telemedicine may only be conducted within an existing veterinarian-client-patient relationship, with the exception for advice given in an emergency care situation until a patient can be seen by or transported to a veterinarian.
*For established patients (those seen within the year), this Consent is valid until the anniversary date of the last Physical Exam visit.

Teleadvice
Teleadvice is the provision of any health information, opinion, guidance or recommendation concerning prudent future actions that are not specific to a particular patient's health, illness or injury. This is general advice that is not intended to diagnose, prognose, treat, correct, change, alleviate, or prevent animal disease, illness, pain, deformity, defect, injury, or other physical, dental, or mental conditions. Examples include recommendations made by veterinarians or non-veterinarians via phone, text or online that all pets should receive annual wellness exams as part of a comprehensive preventive care plan, or that animals living in mosquito-infested areas should receive year-long heartworm preventatives.

Teletriage
Teletriage is the safe, appropriate, and timely assessment and management (immediate referral to a veterinarian or not) of animal patients via electronic consultation with their owners. In assessing patient condition electronically, the assessor determines urgency and the need for immediate referral to a veterinarian, based on the owner’s (or responsible party’s) report of history and clinical signs, sometimes supplemented by visual (e.g., photographs, video) information. A diagnosis is not rendered. The essence of teletriage is to make good and safe decisions regarding a patient’s disposition (immediate referral to a veterinarian or not), under conditions of uncertainty and urgency.

Email *

Client Full Name, Mailing Address, and Contact Info *

Pet's Name / Breed / Age / Female/Spayed / Male/Neutered *

Consent for Telehealth (Teleadvice, Teletriage, Telemedicine) *

This is to certify that I am the owner of the pet described above. I give my consent to engage in audio with video consultation with Dr. Elmar Zamora. I understand that veterinary medical advice/diagnosis and treatment may involve risk of complications, injury, or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. I will comply with the treatment plan formulated unless otherwise expressed as DECLINED. I understand the limitations, advantages, and disadvantages of using Telehealth as a medium to access veterinary medical care. I proceed knowing these and in effect, I, hereby release the doctors and staff of A.E.Z.R Pet Hospital from any liability. I agree to assume financial responsibility for this telehealth consultation. This amount will go towards the consultation fee if it leads to an in-hospital appointment.

I have read, I understand, and give my consent to the statement above. I authorize A.E.Z.R. PET HOSPITAL to charge my credit card $39 for the TELEHEALTH consultation (for established patient and existing condition)

I DECLINE the Telehealth consultation.

I opt for the UNLIMITED Telehealth / e-Visit Consultation for $99/year (see next section)

Other:

Required

UNLIMITED Telehealth / e-Visit Consultation for $99/year *

Other Benefits: Access to Client Portal (book appointment, access records, refill request, etc.)

Yes, I would like to opt for UNLIMITED e-Visit (video, email, text) for 1 year for $99. I understand that this is not for an EMERGENCY VISIT

No, I would like to pay on a per need basis ($39 for 15-minute session)

Brief Medical Question *

Signature and Date Signed *

By typing my full name below, it constitutes my acknowledgment that I have read and understood this authorization. To the best of my knowledge, the information I have provided is true.

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