Influenza Vaccine Form

I, *

First

Last

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.

Signature *

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Consent to Telemedicine

Name *

First

Middle

Last

First and Last are required.

Pet's name *

Phone *

Email *

I agree: *

My veterinarian has offered me the option of a Telehealth Consult. Telehealth appointments are 30 minute appointments that can be done via a phone call or video call. I am undertaking this consultation with the understanding that there are limitations to what my veterinarian can deduce about my animal’s condition without a physical examination and/or other detailed investigations best done in person. To minimize the risks of errors of clinical judgement my veterinarian may recommend an in-person exam and/or further diagnostic tests. This will then be up to me to decide if I proceed. I understand that it is my responsibility to contact my veterinarian and/or bring the pet for an exam at the nearest emergency hospital if my pet’s condition persists or deteriorates unexpectedly. I understand that payment for my consultation and any medications recommended, agreed to and/or delivered to me will be completed in full on my nominated credit card at the end of this consultation. I understand that the cost of my Telehealth consultation does NOT include payment for other services, examples of which include but are not limited to such things as medications, supplements, tests, procedures, diagnostics, referrals to specialists, hospital care, etc. I understand that I am consulting with a veterinary professional employed at Your Visiting Veterinarian LLC who is a licensed Veterinary Practitioner in the state of Ohio. I also confirm that my details including my stated residence in the state of Ohio are correct.

Signature *

Telemedicine SOAP Notes

Influenza Vaccine Form

Decline Doctor's Advice

Name *

First

Middle

Last

First and Last are required.

Address *

City *

State

Zip Code *

Pet's Name *

Pet Species *

Breed

Service(s) that are being declined *

Owner's Consent *

I attest that I am the owner or authorized representative of the animal described above. The veterinarian has advised diagnostics, treatments, and/or other services for my pet and I have chosen to decline the items that are listed above. The doctor has explained to me the potential negative results of my decision and they have answered all of my questions. I understand what we have discussed.

Release of liability *

I release Your Visiting Veterinarian, it's staff, and anyone associated with Your Visiting Veterinarian from any liability, impact, or costs that my decision may result in now and into the future.

Signature *

Consent to Euthanasia

Consent to Share Medical Records

Name *

First

Middle

Last

First and Last are required.

Phone *

Email *

What is your pet's or pets' names that you wish to have us transfer records for? *

Please only list the pet or pets that you wish to have us transfer records for.

What is the name of the clinic, daycare/boarding facility, or individual that you wish to have us share your pet's or pets' records to? *

What is their phone number? *

What is the email address that they wish us to send your pet's records to? *

One time transfer *

I attest that I am the owner of the animal listed above. I give Your Visiting Veterinarian LLC permission to do a one-time transfer of my pet's or pets' medical records to the clinic, hospital, or individual listed above via the email address that I have provided above.

Acknowledge *

I attest that this information is correct and accurate and I release Your Visiting Veterinarian, LLC from any liability or wrong-doing that may occur from the transfer of my pet's or pets' records.

Signature

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Medical Records Note

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