Telemedicine Consent Form

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Telemedicine Consent Form

If this is an emergency, or if your pet needs urgent care, please call us at (706) 387-0006 for a faster response.

Owner's Name: *

First

Last

Patient (Pet) Name: *

Authorization for Phone Communication

I authorize the veterinary staff at Galilee Veterinary Hospital to discuss my pet's medical records, treatment plans, test results, and financial status over the telephone, via text, and via email *

I consent

Authorized Individuals

You may share my pet's medical information with the following people:

Name *

First

Last

Relationship *

Phone *

Email *

Name

First

Last

Relationship

Phone

Email

Contact Preferences

Please use the following phone number(s) for updates:

Primary Phone *

Secondary Phone

Acknowledgment and Signature

I understand that communication over standard telephone lines may not be completely secure. *

I consent

This authorization remains valid until I revoke it in writing. *

I consent

at I financial

Signature *

Clear Signature

Date: *

Telemedicine Consent Form