Telemedicine Appointment Request

Please fill out this form as completely as possible to request a telemedicine appointment. Please contact us with any questions.

"*" indicates required fields

Owner's Name*

First Last

Email*

Phone

Pet's Name

Pet's Breed

Pet's Age

How Would You Like to be Contacted?*

Text

Phone Call

I am a current client of KPAH. I authorize the veterinarian on call today to access my pet’s records to be able to make timely and accurate recommendations for my pet.*

Yes

My Pet's Current Problem Is:*

The Problem Started:*

I Have Already Tried the Following Treatment(s):*

My Regular Veterinarian Is:*

Photo Upload

Upload pictures to give your doctor the best chance to help you and your pet.

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 15 MB.

Service Requested

Teletriage with a Doctor or Veterinary Nurse $ 59.00

Telemedicine with a Doctor from KPAH $ 85.00

Total