Telehealth Consent & Authorization

Telehealth Consent & Authorization
Today's Date:*

MonthDayYear
Client Name:*

First NameLast Name
Your Birthdate:*

MonthDayYear
Pet Name:*
Cell Phone Number:*
Please enter a valid phone number.
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Veterinarian's Name: Dr. Lillian Felz
License Number: VM8032

Please note that Florida Law (Chapter 2024-260) will only allow the dispensing of up to a 1 month supply of products labeled soley for flea and tick control and up to 14 days of treatment for other animal drugs. If medication is prescribed, you may obtain a prescription that may be filled at the pharmacy of your choice. Prescriptions based soley on a telehealth evaluation may not be renewed without an in-person examination. Controlled substances can not be prescribed without the veterinarian conducting an in-person physical examination of the animal as defined in Chapter 893.

For patient follow-up care or assistance—if the veterinarian and client are unable to communicate due to a technological or equipment failure, or if there is an adverse reaction to treatment—contact:

Ibis Animal Hospital
10130 Northlake Blvd Suite 114, West Palm Beach, FL 33412
(561)-625-6970

For any after-hour emergencies, please contact:

VCA Palm Beach Veterinary Specialists
3884 Forest Hill Blvd, West Palm Beach, FL 33406
(561)-434-5700

Pet Emergency and Referral Center
3579 Northlake Blvd, Palm Beach Gardens, FL 33403
(561)-691-9999

Veterinary Specialty Hospital of Palm Beach Gardens
4019 Hood Rd, Palm Beach Gardens, FL 33410
(561)-625-9995

ACCESS Specialty Animal Hospital
10465 Southern Blvd, Royal Palm Beach, FL 33411
I hereby authorize the veterinarian to provide healthcare services through the use of a telemedicine provider. I hereby state that I am over 18 years of age, I am the owner (or authorized representative of the owner) and I have the authority to make both medical and financial decisions regarding this animal. I assume responsibility for all charges incurred in the care of the animal(s) listed on said form. I also understand and agree that these charges will be paid in full at the time services are rendered. I have recieved all required information before the veterinary telhealth services take place.*

Powered by Jotform SignClear
Should be Empty: