Telemedicine Notification Form

Name of Practicing Veterinarian that plans to establish a VCPR through Telemedicine alone (please note that the Practicing Veterinarian Member must complete this form).*

Name of Clinic that holds a Telemedicine Permit (please note that the clinic must apply for a permit prior to completing this form)*

Email address*

I am completing this Notification Form as I intend to establish a VCPR through telemedicine alone.*

Yes

By completing this form, I agree:

1. To follow The Veterinary Medical Act, the MVMA General By-Laws, the Code of Ethics and the MVMA PIPS By-Law when providing service via telemedicine.*

Yes

2. To keep a list of all telemedicine files. (Telemedicine files: Patient files where a VCPR is established without a hands-on examination of an animal and/or visiting the premises where the animal is kept. This applies to both new and existing patients where there has not been a hands-on examination of an animal and/or visiting the premises where the animal is kept within the last 12 months.)*

Yes

3. That I will document the compelling justification and rationale for why establishing a VCPR solely via telemedicine is needed.*

Yes

4. That I will not prescribe any Controlled Substances, Benzodiazepines, or class-Z drugs for these patients without conducting a hands-on examination or visiting the premises where the animal is kept.*

Yes

6. That I will not establish a VCPR for a group of animals (for example, a herd, flock, or school) via telemedicine unless the animals are intended for personal use only and there is no reasonable access to veterinary care. Further, if a VCPR is established via telemedicine for a group of animals, the veterinarian providing service will document on the medical record the information that is used to justify his/her knowledge that the animals are intended for personal use only.*

Yes

7. That when do the following while providing service via telemedicine: *

	Yes
a. Disclose their identity, location, and license status;
b. Confirm the identity of the client and animal(s);
c. Consider the existing health status of the animal or group of animals, the specific health needs and specific circumstances, and only use telemedicine if the risks do not outweigh the potential benefits;
d. Identify what resources (e.g., information and communication technology, equipment, support staff, etc.) are required, and only proceed if those resources are available and can be used effectively;
e. Ensure the reliability, quality, and timeliness of the information obtained;
f. Protect the privacy and confidentiality of the client’s and animal(s) information, inclusive of evaluating the technology and the physical setting;
g. Ensure the physical setting in which the care is being delivered is appropriate and safe, including having a plan to manage adverse events and/or emergencies;
h. Explain to the client any limitations of proceeding with telemedicine to provide the veterinary services required;
i. Provide access to in-person follow-up care in Manitoba.

Date*

Date

Signature*