Avian Home Veterinary Care, PLLC

Jessica L. Grodio, DVM, PhD, DABVP (Avian)

COVID-updated service: Video chat waiver and credit card approval

Video chat form

Name (First & last name of owner) *

Name and species of pet *

I am requesting *

Required acknowledgements (must check ALL boxes) *

I understand that this consult is for general care and general health information only.
I understand that the veterinarian will NOT be able to give my pet a diagnosis/prognosis from a video consult/photo.
I understand that treatments/medications CANNOT be prescribed based on a video consult/photo alone. A veterinary-client-patient relationship must exist to prescribe medications; the patient must have had recent physical exam with the prescribing veterinarian.
I understand that this consult should not be used in place of seeking medical attention for ill animals.

I am requesting (chose one) *

general consult - $75 up to 30 minutes
brief consult (for patients seen within last 6 months only) - $50 up to 20 minutes

If my consult goes longer than the initial allotted time, I *

DO approve of an additional charge of $40 per 20 additional minutes
DO NOT approve of an additional charge of $40 per 20 additional minutes (in which case the consult will end at the initial time limit)

Dr. Grodio will give you a reminder when the initial consult time is up.

Name on credit card *

Credit card type (VISA, AMEX, etc) *

Credit card number *

Card expiration date *

month/year

Security code *

either 3 digits on back, or 4 digits on front

Billing zip code *

Credit card payment agreements (must check ALL boxes) *

I give Avian Home Veterinary Care , PLLC authorization to charge my credit card for the consult I selected above.
I understand my credit card will be charged for the initial consult time immediately PRIOR to the consult, and if the consult goes over the allotted time, the additional time fee will be charged to my credit card AFTER the consult.
If I opt to cancel my scheduled appointment, a $10 processing fee will be incurred during refund. I agree to give Dr. Grodio 24 hours notice if I need to cancel or change my appointment time. No refunds are given after the consult has taken place or if I miss my scheduled appointment.

Name