Appointment Request Active Patient

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

Active Patient Appointment Request Form

CURRENTLY BOOKING APRIL

Please submit TeLeVET Time request form for further assistance. Thank you

This form is for ACTIVE CLIENTS with active patients that have utilized services within the LAST 12 MONTHS.

If it has been GREATER THAN 12 MONTHS since your pets last exam or treatment please submit an updated NEW CLIENT FORM

ONE HEALTH CONCERN PER APPOINTMENT REQUEST PLEASE

Thank you

Click for additional Active Client Forms (ie new pet to household, etc)

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 and submit new client request form



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)
Housecall-Integrative (both Western and TCVM)
TCVM Herbal Consult only
TCVM Food Therapy Only
Quality of Life-In Home Euthanasia

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