INFORMED CONSENT FOR TELEMEDICINE CONSULTATION

This consultation involves the use of electronic communications to enable Dr. Beebe to recommend therapeutic options for your pet. The information provided may be used for diagnosis, therapy, follow-up and/or education, and may include the following:

• Patient Medical Records

• Medical images

• Live two-way audio and video

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client and patient information.

BY SIGNING THIS FORM I UNDERSTAND THE FOLLOWING;

• That the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.

• A variety of alternative and integrative method/options for veterinary care are available depending on the condition of the individual patient, and I may choose one or more of these at any time. 

• Dr. Signe Beebe is consulting on alternative and integrative methods of treatment including, but not limited to, acupuncture, Chinese herbs, Chinese food therapy, intravenous vitamin C, prolotherapy, neural therapy, gold wire implantation, veterinary Tuina, laser therapy, ozone, microbiome restoration, veterinary manipulative therapy (chiropractic), ozone therapy and nutritional supplements, some of which may or may not be recognized as standard methods of treatment by the American Veterinary Medical Association (AVMA) as well as conventional medicine.

• The nature and purpose of the therapeutic options and the risks involved in these treatments are known to me.

• I may expect anticipated benefits for my animal(s) from the use of telemedicine, however no guarantee or assurance has been made as to the result that may be obtained.

• I understand that recommendations for the treatment of my animal are in accordance with prevailing standards of competency in the above-described modalities of treatment as recognized by the AVMA, American Academy of Veterinary Acupuncture, the International Veterinary Acupuncture Society, the Chi University of Traditional Chinese Veterinary Medicine, Chi University of Traditional Chinese Veterinary Medicine,  the Veterinary Botanical Medicine Association the American Holistic Veterinary Medicine Association and the American College of Veterinary Botanical Medicine.

• It is highly recommended that you have a primary care veterinarian that can evaluate your pet in person. As no physical examination of your pet has been performed by Dr. Beebe, she will not be able to prescribe any conventional drugs; for this you will need a primary care veterinarian. Herbal medications and supplements can be prescribed as needed as they are not regulated as drugs. 

• CANCELLATION POLICY Please reschedule or cancel your consultation a minimum of 48 hours prior to your scheduled time. If you have paid for your consult and cancel in less than 48 hours, a cancellation fee will apply. Canceling your appointment after this time prevents other sick pets from being scheduled that need help.  By signing below you acknowledge and agree to the cancellation policy as outlined here. 

I have read and understand the information provided above regarding this consultation and the cancellation policy. I hereby give my informed consent to the use of telemedicine in my animal’s medical care. I grant to Dr Signe Beebe, and her representatives the right to publish photographs of my pet(s) on her website and social media. I assume all financial responsibility for charges incurred for consulting services provided by Dr Signe Beebe in regards to the potential treatment of my animal and understand that payment is required in full one business week (5 days) prior to my consultation. This agreement shall remain in effect unless a different agreement is executed. (Please sign below)