Telemedicine File Submission Form
Name of Clinic:
*
Name of person completing the form:
*
Email address:
*
Name of client:
*
Name of patient:
*
Date of telemedicine service:
*
-
Month
-
Day
Year
Date
Compelling reason for establishing a VCPR via telemedicine:
*
Were Controlled Substances, Benzodiazepines, or class-Z drugs prescribed to the patient?
*
Yes
No
Please provide information as to the Controlled Substances, Benzodiazepines, or class-Z drugs that were proscribed and the reason for doing so. Please note that under the MVMA By-Laws, Controlled Substances, Benzodiazepines, or class-Z drugs cannot be prescribed when a VCPR is established via telemedicine alone.
Was service provided to a group of animals?
*
Yes
No
If yes, please describe the information that you relied on to ensure that the animals were for personal use only.
*
Upload the medical file for the patient. Please use the following naming rules for the document: Veterinary Corporation name (or) Veterinarian last name, Patient name.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I agree to pay the Telemedicine File Fee below:
*
Yes
*
prev
next
( X )
Telemedicine File
Telemedicine File Fee $10+gst
$
10.50
CAD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Date:
*
-
Month
-
Day
Year
Date
Signature:
*
Submit
Should be Empty: