Dutch Informed Consent

MARGOT HEALTH, P.C.
INFORMED CONSENT REGARDING USE OF VETERINARY TELEMEDICINE SERVICES

 

Provider Information:

Name

State(s) and (License Number)

Contact

Dr. Brian Evans

Idaho (V5842)

brian@sdcoastalanimal.com

Dr. Jenerson Zachary Coston

Indiana (24008486A)

arborealsrock@gmail.com

Dr. Changseok Kim

Michigan (6901010816)

newkcs@icloud.com 

Dr. Victoria Benson

Michigan (6901011763)

docvdvm2018@gmail.com

Dr. Jacqueline Brewer

New York (008439)

shihatajacqueline@yahoo.com 

Dr. Paul Smith

New York ( 007673-01)

New Jersey (29V100786000)

jandp2008@aol.com

Dr. Jennifer Jones

New York (09956-01)

jonesjl_cat@yahoo.com

Dr. Casey McMahon

Pennsylvania (BV015638)

drcaseymcmahon@gmail.com

Dr. Lisa Coder

South Dakota (1812)

lisacoder@gmail.com

Dr. Melanie Crovo

Virginia (0301007329)

melcrovo@gmail.com

Dr. Mindy Joyner

Virginia (0301205827)

drmjoyner@gmail.com

Dr. Diane Kraszny

Virginia (0301005290)

Pets@actioncarevet.com

Dr. Stephanie Gaddam

Virginia (0301204900)

stephgaddam@gmail.com

 

PURPOSE

The purpose of this form is to provide you with information about veterinary telemedicine and to obtain your informed consent for our providers to perform veterinary telemedicine services as part of the medical care of 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 to 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. 


VETERINARY TELEMEDICINE ENCOUNTERS

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.


BENEFITS

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.


POTENTIAL RISKS

The potential risks associated with the use of veterinary telemedicine can include delays in veterinary medical evaluation and treatment 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.  


INDEMNIFICATION

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.


ALTERNATIVES

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 has an adverse reaction to treatment, if a technical failure prevents you from communication with one of our providers. If you don’t hear from care@dutch.com, 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.


YOUR PRIVACY RIGHTS

The Practice uses network and software security protocols to protect the confidentiality of your personally identifiable information (including, for example, your personal financial data) and the medical information concerning your Pet. These protocols are designed to safeguard the data and to ensure its integrity against corruption. Personal information that identifies you will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in the Practice’s Privacy Policy.


By consenting to this form, I understand the following:

Veterinary telemedicine 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, but that results cannot be guaranteed. My provider will inform me who will be present at the provider’s location during the veterinary telemedicine 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 telemedicine 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 telemedicine encounter prior to the start of my visit. 

Further, I understand that the laws that protect privacy and the confidentiality of personally identifiable information and medical information about my Pet also apply to veterinary telemedicine and I agree that the Practice may provide any such information 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 telemedicine 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 TELEMEDICINE ENCOUNTER AND TO HAVE MY PET EVALUATED AND TREATED VIA SUCH VETERINARY TELEMEDICINE ENCOUNTER AND FURTHER CONSENT TO THE BELOW:

  • 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 telemedicine 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 have read, understand and agree to the Practice’s Privacy Policy
  • 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. Notwithstanding the foregoing, I understand that I am free to obtain prescriptions from any pharmacy of my choice. Please send an email to care@dutch.com 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 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 care@dutch.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 care@dutch.com 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).