*2021_Ask a Brief Medical Question
By filling up this form, I acknowledge that this is not for an emergency.
Client Full Name, Mailing Address, and Contact Info
Pet's Name / Breed / Age / Female/Spayed / Male/Neutered
Brief Medical Question
Consent for Telehealth (Teleadvice, Teletriage, Telemedicine)
This is to certify that I am the owner of the pet described above. I give my consent to engage in video/phone/text/email consultation with Dr. Elmar Zamora. I understand that veterinary medical advice/diagnosis and treatment may involve risk of complications, injury, or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. I will comply with the treatment plan formulated unless otherwise expressed as DECLINED. I understand the limitations, advantages, and disadvantages of using Telehealth as a medium to access veterinary medical care. I proceed knowing these and in effect, I, hereby release the doctors and staff of A.E.Z.R Pet Hospital from any liability.
I have read and I understand the statement above and give my consent
I DECLINE the Telehealth consultation.
Full Name and Date Signed
By typing my full name below, it constitutes my acknowledgment that I have read and understood this authorization. To the best of my knowledge, the information I have provided is true.
Send me a copy of my responses.
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of A.E.Z.R. Pet Hospital.