Urgent Veterinary Appointment Form

Urgent Veterinary Appointment Form

Florida
This form is for a veterinary telemedicine appointment.

You can choose to have your appointment immediately (IN THE NEXT 60 MINUTES OR LESS) or within the next 24 hours.
Select Appointment Type

URGENT - appointment in 1 hour or less - cost: $125Today - appointment within the next 24 hours - cost: $69
Owner Information
Name*

First NameLast Name
Phone Number*
Please enter a number where you can be reached.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Information
Pet's Name*
Species
Gender
What is the immediate concern with your pet?
(optional) upload any related documents here (previous records, pictures, etc.)

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Please be aware that a prescription may be provided when medically appropriate and permitted by Florida law. The prescription will be emailed to you immediately, and you may use it at online pharmacies (like chewy.com) or your local pharmacy that carries veterinary medications. In some cases, certain medications (especially narcotics) cannot be issued by telehealth.
I have read the above statement and understand that FL law has some limitations regarding veterinary telemedicine and prescriptions. l understand that appointment costs are paid upfront using a secure online payment link which will be sent to me after I submit this form.*

I Agree
How do you want the vet staff to contact you now to confirm your appointment and send the payment link?

textemail
Pet Owner's Signature*
Date Signed*

MonthDayYear
Date
Should be Empty:

Urgent Veterinary Appointment Form

Owner Information

Pet Information