Appointment Request Active Patient

BROWN VETERINARY

HOUSECALLS

Integrative Veterinary Medicine for Dogs & Cats- Valley Wide

EQUINE

MOBILE ACUPUNCTURE

Traditional Chinese Veterinary Medicine (TCVM) for Horses-Valley Wide

SOUL PUPPY

HOLISTIC HEALING

Downtown MESA TCVM-Acupuncture Specialty Office for Dogs & Cats

BROWN VETERINARY HOUSECALLS

Local-Small Business-Private Practice

Colleen Brown DVM

HOLIDAY SCHEDULE

Christmas Closed Dec 23-27

New Years Closed Jan 1

December schedule closed to new clients

NOW BOOKING JAN 2025

EMERGENCY RESOURCES

#notonemorevet

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

Active Patient Appointment Request Form

HOLIDAY SCHEDULE IN EFFECT

This form is for ACTIVE PATIENTS with a current VCPR i.e. in person exam or treatment with Dr. Brown within the LAST 12 MONTHS.

If it has been GREATER THAN 12 MONTHS please submit an updated NEW CLIENT FORM

One health concern per appointment please

Thank you

THIS IS NOT A NEW CLIENT FORM!

Appointment Request Form-ACTIVE

Please confirm active client-patient status before continuing with form as practice policies may have changed (required)

I am an active client and Dr. Brown has treated this pet before within 12 months-please continue with form
I am an active client within 12 months with new pet to become a new patient-please continue with form
I am NOT an active client and wish to become a new client-PLEASE STOP-DO NOT SUBMIT THIS FORM - please submit a new client request form via new client links. Thank you



First Name	Last Name

Phone (required)
Phone Type	Phone Number (required)

Email address (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Patient Name

Species

Dog
Cat
Horse

Breed

Age of Patient

Sex of Patient

Female-intact
Spayed
Male-intact
Neutered
Mare
Stallion
Gelding

Color of Patient

Reason for appointment/main concerns (required)

Duration of above concern(s) or condition(s)

Goal of treatment

Diet and frequency of meals

Medications-please list all including strength and frequency of dosing

Supplements or Herbs

Is your pet on heartworm prevention?

Yes
No

Is your pet on flea or tick prevention

Yes
No

Please list type of heartworm or flea and tick prevention

Is your dog, cat or horse current on vaccines

Yes
No
Unsure

Does your pet have a history of vaccine reactions?

Yes
No
Has never had vaccines

If your pet has had a previous vaccine reaction, please list which vaccine i.e. distemper/parvo, rabies, etc

Has your pet had a full blood panel in the past 12 months?

Yes
No
Unsure

Does your pet have a history of Valley Fever?

Yes
No
Never been tested

Please list any pertinent history of chronic conditions i.e. abnormal blood work, renal or liver disease, heart murmur, seizures, colic, laminitis, navicular, etc.

Please list any pertinent history of previous surgery or dental cleanings/teeth floating along with approximate year or age of procedure

Type of Appointment Requested (required)

Soul Puppy Holistic Healing-TCVM (acupuncture)
Housecall-General Medicine (wellness/prevention)-starts at $199
Housecall-General Medicine (sick/injured/nonemergency)-starts at $222
Housecall-TCVM (acupuncture for dogs, cats or horses)
Housecall-Integrative (both Western and TCVM)
TCVM Herbal Consult only
TCVM Food Therapy Only
Quality of Life-In Home Euthanasia

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