Telehealth Authorization Form

Marked fields are required (*)

I authorize Christensen Animal Hospital, Dr. Jeffrey R. Moll and his staff to consult with me via telecommunication (“Virtual Visit”) for the evaluation of the behavior, environment, and welfare of my pet including audio and/or video recording of video chat sessions. Photos and/or videos submitted to Dr. Moll and staff may be used for assessment, and I allow use of this media to others for consultation or educational purposes. I assume responsibility for all charges for this and any future consultations. Telecommunications with Dr. Moll and the veterinary staff is limited to the hours of availability as determined by the veterinary staff (within business hours). A $65 telecommunication fee is charged at the time of the Virtual Visit. Should my pet have to be dropped off for physical examination on the same day as the Virtual Visit at Christensen Animal Hospital, a $35 credit will be applied to the total charges for that day. At no time beyond the same day services will a credit be applied when associated with the same Virtual Visit.*
- I have read and understand this authorization and consent.
Pet's Name*
Date
MM slash DD slash YYYY
Owner Name*
First Last
Email*
Owner Consent acts as Digital Signature*
- I Consent
Signature*
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Comments
This field is for validation purposes and should be left unchanged.

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