Animal Care Express Services Teletriage Request

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Please enter a valid phone number.

Is this a mobile phone number?*

YesNo

Email*

example@example.com

Pet Name*

Species*

CanineFeline

Sex*

FemaleMaleFemale/SpayedMale/Neutered

Breed*

Color

Age*

Date of Birth

Please describe question or concern for teletriage communication request.*

Teletriage Requested Date and Time

Is your pet scheduled for medical treatment/services with us?

YesNo

Referring Hospital

Referring Veterinarian

Authorization to share your pet's information with your veterinarian:

YES- I authorize Animal Care Express Services to share information for my pet ONLY to the veterinarian listed on this form.NO- I do NOT authorize Animal Care Express Services to share discharge information with any veterinarian.

I hereby declare that I am the legal owner of the pet given its name above and give my consent for my pet to participate in all activities conducted by Animal Care Express Services.

ACE’s providers may, in appropriate circumstances, provide teletriage or teleadvice services to clients for their pets.

“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.

“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.

By confirming this appointment, I understand that I am receiving teletriage or teleadvice by a licensed veterinary technician that can not provide a diagnosis, treatment, or medication as outlined in the South Carolina Association of Veterinarian’s code of laws.

Date*

Date

Teletriage Consult Options - Please Select ONE:

Teletriage Service - Phone Call Product Image

Teletriage Service - Phone Call Providing professional triage or advice based on patient needs. This is for placing a phone call to ACES.

$15.00

Teletriage Service - Video Chat Product Image

Teletriage Service - Video ChatProviding professional triage or advice based on patient needs. This is for placing a video call to ACES.

$22.00 Quantity
Item subtotal:$0.00

Total

$0.00

Once payment is submitted, directions for your phone call or video chat will be sent to you via text.

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Animal Care Express Services Teletriage Request

Client Information

Pet's Information

Reason For Teletriage

Please Sign The Following Authorization

Method of Payment

Once payment is submitted, directions for your phone call or video chat will be sent to you via text.