Thank you!!

living at 107 Blakemore Drive, Delaware, OH 43015, agree to the following:

I attest that I am the owner of Henley Siegle-Phillips, a black and tan German Shepherd canine.

I have elected to have the initial bandage application and subsequent care completed over telehealth with Your Visiting Veterinarian (YVV) and YVV has agreed to do so. In-person appointments and a referral to a brick-and-mortar animal clinic were advised and I have declined both.

Rechecks via video call, phone call, or email will be advised based on YVV's veterinarian’s medical judgment of what is in Henley’s best interest. I agree to follow the schedule that YVV's veterinarian will determine and I agree to reply to all communication promptly. YVV has agreed in kind.

All remote consult time (research, email communication, or phone communication) related to Henley will be billed daily at $180 per hour in 20-minute increments. Any previous balance must be paid in full before additional services are rendered. This can be done via credit card over the phone by calling YVV's business phone number: 740-899-5789.

Pricing is as followings:
- 1-20 minutes: $60
- 21-40 minutes: $120
- 41-60 minutes: $180
- 61-80 minutes: $240
- Etc.

Telemedicine appointments done via video call will be up to 30 minutes and cost $95. Any additional time over the 30 minutes will be billed at the rate mentioned previously. YVV's telemedicine consent form must be signed prior to my initial telemedicine appointment and can be found under the “Contact Us” tab of YVV's website or on the previous page.

Since the MicroLyte bandages are being specially ordered for Henley, I will pay for them prior to them being ordered and I understand that there will be no refund available. In addition, I will be billed $60 to mail the samples, which includes the costs required to prepare and transport samples to the carrier and the shipping cost.

YVV will give me advance notice should any fee increases be required due to the increasing cost of goods or services.

An in-person exam must be completed every twelve months to continue remote care. Henley’s last in-person appointment was January 23rd, 2023.

While we certainly hope for a very successful outcome for Henley, I understand that remote care of Henley does not guarantee a successful outcome, even if all instructions are followed. If YVV determines unsatisfactory improvement of Henley’s condition(s) or inadequate compliance, YVV may warrant a change to this agreement. One such change may be the requiring of in-person care or a referral to a brick-and-mortar clinic. If YVV and I cannot agree to the new terms, at that time YVV may elect to no longer provide care for Henley. At such point YVV will email Henley’s records to any veterinary clinic I wish.

I sign, indicating that I have read, understand and agree to the terms and conditions to manage Henley remotely.

First and Last are required.