Dutch Informed Consent
INFORMED CONSENT REGARDING USE OF VETERINARY TELEHEALTH SERVICES
|Name||State(s) and (License Number)|
|Brian Evans||Idaho (V5842)|
|Twila Booke||Delaware (N1-0002953), Virginia (0301205712)|
|Jessica Larson||Florida (VM15061), Washington (VT60922637)|
|Chris Logan||Florida (VM16911), Oklahoma (3904)|
|Tanya Robinson||Florida (VM15087), Georgia (VET010359)|
|Val Fournier||Florida (VM17139), Georgia (VET010657), Michigan (6901009719)|
|Linsay Barnes||Georgia (VET006987), Michigan (6901400853)|
|Eboni Lee||Georgia (VET009048)|
|Sam Zayas||Colorado (VET0012153)|
|Lauren Barrow||Colorado (VET0009617), Virginia (0301206351)|
|Hannah Lewis||Colorado (VET0011249), Ohio (VET.202882), Indiana (24008978A)|
|Sandra Ruland||Colorado (VET.0008003)|
|Yasuko Stephens||Hawaii (VE-407)|
|Melissa Putnam||Hawaii (VE-1033), Colorado (VET.0010996)|
|Nicole Van Abel||Indiana (24008813A), Michigan (6901400889)|
|Greg Skelton||Indiana (24007542A), Ohio (VET.10927), New York (010876)|
|Christa Cheatham||Indiana (24008671A)|
|Jennifer Duran||Illinois (090-009261)|
|Leigh Meyer||Iowa (6740)|
|Sherri Stello||Kentucky (24008644A), Indiana (146926)|
|Yolanda Skinner||Louisiana (2020), Arkansas (9048), Iowa (7657), Alabama (7657), Georgia (VET011178)|
|Clarisa Krueger||Louisiana (3701)|
|Katherine Saenger||Maine (1032), South Carolina (1314)|
|Hannah Braught||Massachusetts (7045), Pennsylvania (BV016236)|
|Caryn Adrian||Michigan (6901400654), Colorado (VET.0008680), New Mexico (DVM-3446)|
|Kari Smith||Michigan (6901400508)|
|Janet Johnston||Michigan (6901400938)|
|Amanda Grant||Michigan (6901010347)|
|Kody Carr||Minnesota (10719)|
|Vanessa Domann||Missouri (2006015553)|
|Pamela Fonti||Missouri (2006036698)|
|Rebecca Dallam||Missouri (VM15868), New York (VE-1051), Florida (2016034120), Hawaii (014207-01)|
|Ross Pinkelman||Nebraska (3843), Florida (VM17458)|
|Darcy Schlothauer||Nebraska (3081), Wyoming (1697)|
|Rebecca Boncheck||New Jersey (VM14249), South Carolina (29VI00332800), Florida (3525)|
|Liv Wallin||New Jersey (29VI00581100)|
|Tara Griffin||New Jersey (29V100672300)|
|Jennifer Lesser||New Hampshire (2030), Vermont (052.0080442)|
|Brandt Payne||New York (14168)|
|Christopher Rubbert||New York (007931), Florida (VM16509), South Carolina (4685)|
|Paul Smith||New York (007673-01), New Jersey (29V100786000)|
|Miguel Maqueda||New York (007977-01)|
|Jennifer Wiegel||North Carolina (), Virginia ()|
|Liz Wieczorek||Ohio (10975)|
|Deepti Johar||Ohio (202157), New York (014233)|
|Dianna Funk||Ohio (VET.8362)|
|Oluwafemi Olaitan||Oklahoma (6475), Washington (VT61127459), Pennsylvania (BV016271), Delaware (N1-0013080), Oregon (8413), Virginia (Pending)|
|Rachael Baldwin||Oklahoma (6115)|
|Emily Keith||Oklahoma (5273)|
|Matthew Nelson||Oregon (6160)|
|Danielle Behrends||Oregon (7948)|
|Janice Goode||Pennsylvania (BV008231L), New Jersey (29VI00440900)|
|Melody Conklin||Pennsylvania (BV011632)|
|Andrew Rosenfeld||Pennsylvania (BV010873)|
|Angela Cooper-Carty||Pennsylvania (BV009014L)|
|Jennifer Matera||South Carolina (2785)|
|Sally Lanford||South Carolina (1256)|
|Stephanie Cruz||South Carolina (3853)|
|Sara Johnston||South Carolina (2369)|
|Edward Kreider||South Dakota (1240), Minnesota (18120)|
|Jennifer Corbin||Virginia (0301202845), Florida (VM9258)|
|Evymarie Prado-Sanchez||Virginia (301205264)|
|Leslie Sheridan||Virginia (301200770)|
|Carolyn Edson||Virginia (301205401)|
|Joy Bailes||Washington (VT60611707)|
|Sruti Sreerama||Washington (VT00008957), Pennsylvania (BV016454)|
|David Abolnik||Washington (VT61142651)|
|Karee McBroom||Washington (VT61037889)|
|Vanessa Herreid||Washington (VT60610476), Pennsylvania (BV012409), Ohio (VET.10391)|
|Marilyn Connor||Wyoming (1813), Alabama (7562), Florida (VM14455), Kentucky (247467), New York (015375)|
The purpose of this form is to provide you with information about veterinary telehealth and to obtain your informed consent for our providers to perform veterinary telemedicine services or veterinary teletriage (collectively “telehealth”) services for your animal (your “Pet”).
NATURE OF VETERINARY TELEMEDICINE
Veterinary telemedicine involves the use of electronic communications to enable you to share medical information about your Pet with one of our providers at a different location for the purpose of enabling the provider to evaluate, diagnose, consult, and provide treatment for the Pet. Veterinary telemedicine allows our providers to establish a veterinarian-client-patient relationship, much as they would during a traditional face-to-face appointment, and as part of the medical care of your Pet.
NATURE OF VETERINARY TELETRIAGE
Veterinary teletriage involves the use of electronic communications to enable you to share medical information about your Pet with one of our providers at a different location for the purpose of enabling the provider to provide safe, appropriate, and timely assessment under conditions of uncertainty and urgency of your Pet for purposes of assessing the need for immediate referral to an in-person veterinarian or not.
Your veterinary telemedicine encounter with Margot Health P.C. (the “Practice”) may include interaction through and with the use of the internet, audio communications, review of images and medical history submitted by you with respect to your Pet, and diagnoses, as well as related technologies known as “store-and-forward” technologies. Our providers are also always available for follow-up questions and concerns by phone and email.
If your encounter with the Practice is limited to veterinary teletriage, your encounter may include interaction through and with the use of the internet, audio communications, review of images and medical history submitted by you with respect to your Pet, as well as related technologies known as “store-and-forward” technologies. You may receive general information based on the information you provide about your Pet, but will not receive information or advice specific to your Pet, and will not receive any diagnosis, prognosis, or treatment (e.g. a prescription for medication).
The benefits of veterinary telemedicine include improved access to veterinary medical services and care, including the expertise of specialists and consultants that may not otherwise be available to you and your Pet. In some circumstances, veterinary telemedicine can increase efficiency in evaluations, diagnoses, consultations, and treatment. The benefits of veterinary teletriage include improved and timely access to veterinary information in potentially urgent situations when your Pet may be experiencing a life-threatening emergency requiring immediate veterinary care.
The potential risks associated with the use of veterinary telehealth can include delays in veterinary medical evaluation and treatment, or in the ability to provide or receive information, due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of personally identifiable information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors with respect to your Pet due to your failure to provide complete medical information or records regarding your Pet. Further, in some situations, veterinary telemedicine is not an appropriate method of care. Your veterinarian may refer you to a local veterinarian if they determine an in-person visit will be in the best interest of your pet.
YOU AGREE TO INDEMNIFY AND HOLD HARMLESS THE PRACTICE, ITS EMPLOYEES, AGENTS, DIRECTORS, AFFILIATES, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF VETERINARY TELEMEDICINE, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE PRACTICE’S NEGLIGENCE.
Alternative methods of care may be available to you, such as in-person services for your Pet or care from your primary veterinarian.
FOLLOW-UP CARE; EMERGENCY SITUATIONS
If there is an urgent situation involving your Pet, if your Pet may have had an adverse reaction to treatment, or if a technical failure prevents you from communication with one of our providers through the telehealth platform, you may contact the Practice using the contact information below. If the contacts listed below are unavailable, you must seek care for your Pet at an emergency veterinary facility or other provider equipped to deliver urgent or emergent care for your Pet.
I understand that I am obligated to notify the Practice in writing in the event I and/or my Pet have relocated to another State so that my Pet’s professional care may be transferred to a healthcare provider licensed in the State in which we now reside.
YOUR PRIVACY RIGHTS
If you believe a licensed veterinarian, registered veterinary technician or unlicensed person’s behavior or activities may cause harm to animal patients or may be illegal, you can file a complaint with the veterinary licensing board in your State.
By consenting to this form, I understand the following:
Veterinary telehealth is the use of electronic information and communication technologies by one of our providers to deliver services to my Pet when my Pet is located at a different site than the provider. I understand that I need to provide a full and accurate medical history, including any pre-existing conditions of my Pet and any medications that my Pet is taking to the provider so that the provider can accurately determine what services my Pet needs. I further understand that my provider will determine whether veterinary telemedicine is appropriate for my Pet at this time, based on the condition being diagnosed and/or treated. I understand that my Pet may benefit from telemedicine and/or teletriage, but that results cannot be guaranteed. My provider will inform me who will be present at the provider’s location during the veterinary encounter and that I have the right to exclude anyone from being present, if I so choose. I further understand that I have the right to object to the use of a veterinary telehealth service without prejudice to any future care or treatment of my Pet. I understand that I will be informed of the cost of my veterinary telehealth encounter prior to the start of my visit. Your pet’s veterinarian may, after establishing a VCPR, in some circumstances recommend a prescription of an extra-label drug (meaning the use of an FDA approved drug in a manner that is not in accordance with the approved labeling, such as a drug approved for human use) for the pet, and the vet will discuss this option and the risks and benefits with you.
Further, I understand that certain laws that protect privacy and the confidentiality of personally identifiable information and medical information also apply to veterinary telehealth and I agree that the Practice may provide any such information about me and my Pet to other veterinary providers who may be located in other areas, including on rare occasions to veterinary providers outside the State, as necessary. I have the right to inspect and obtain copies of all such information, including any information received and recorded during any veterinary telehealth session, subject to the policies of the providers involved in my care. I may be charged a fee for copies of my records in accordance with applicable State rules.
I have read and understand the information above and all of my questions have been answered to my satisfaction.
I UNDERSTAND AND AGREE THAT I CONSENT TO PARTICIPATE IN THE VETERINARY TELEHEALTH ENCOUNTER AND TO HAVE MY PET EVALUATED AND TREATED VIA SUCH VETERINARY TELEHEALTH ENCOUNTER AND FURTHER CONSENT TO THE BELOW:
- I understand that my provider will determine whether veterinary telemedicine is appropriate for my Pet at this time. I also understand that I may reside in a State that only permits the Practice to provide teletriage services.
- I understand that if my Pet receives teletriage services only, the provider will not render any diagnosis, suggest any treatment, or prescribe any drug for my Pet.
- I understand that the Practice and its providers have a financial relationship with Dutch Pet, Inc. (“Dutch”), who provides management services to the Practice, and that I am free to obtain an evaluation and/or treatment for my Pet elsewhere.
- I further understand that I will be responsible for any payments that apply to the veterinary telehealth visit. I agree that I will not submit the bills for these services to any commercial health insurance plan or other third-party payor.
- I understand that the Practice and Dutch work with affiliated pharmacies (the “Affiliated Pharmacies”) with whom the Practice and Dutch have a financial relationship. I understand that the use of the Affiliated Pharmacies may result in additional benefits such as discounted rates on prescriptions, prescription fulfillment, and/or direct delivery of my prescriptions to my home in the event that my provider prescribes my Pet a drug following a telemedicine encounter. Notwithstanding the foregoing, I understand that I am free to obtain prescriptions from any pharmacy of my choice. Please send an email to firstname.lastname@example.org if you would prefer to have the prescription sent to a different pharmacy, and please include the name, address, and phone number of the pharmacy. We will ensure that your prescription is sent to this other pharmacy.
- I understand that I may not obtain, or attempt to obtain, a telemedicine or teletriage visit through the Practice for an animal or pet that is not my own Pet.
- I understand any prescriptions ordered and delivered to me by the Practice are prescribed only for, and may only be administered to, my Pet. I acknowledge that such prescriptions are never for human use and I will administer any such prescriptions to my Pet as prescribed.
- I understand that I may request for the Practice to send information regarding my Pet’s veterinary care and treatment, including about my personally identifiable information and/or medical information about my Pet, to my local veterinarian. (Please send your local veterinarian contact information to email@example.com and we will forward along such information.)
- I agree that the Practice may communicate with me, including about my personally identifiable information and/or medical information about my Pet, using the following methods and contact information I have associated with my User Account for the website and/or mobile application operated by Dutch: (i) by sending me an email; (ii) by leaving me a voicemail message; and (iii) by texting me. I understand that if I would like to opt-out of being contacted by any of these methods, I may send an email to firstname.lastname@example.org requesting the opt-out.
- I agree to the above methods of unencrypted communication for my own convenience, and I accept all risks associated with them (including, without limitation, risks of improper exposure of my personally identifiable information and/or medical information about my Pet).