Herbal Prescription Refill Form

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

Brown Vet Triple Logo

gray herbal icon Herbal Prescription Request & Refill Form

 This form is for herbal prescriptions &  refills for current TCVM patients being actively treated with acupuncture & herbal medicine by Dr. Brown. VCPR required by law. 


medicine iconPROCESSING INFO

yin yang icon Please submit this form for all Herbal PrescriptioRefill requests & Nutriherb or Mushroom orders

yin yang icon Please allow up to 1 to 3 business days  for approval and processing via Dr. Brown (does not include Jing Tang processing or shipping time). Learn more . Payment must be received prior to shipping. 

Herbal Rx Refill Request

Name (required)
First Name (required)
Last Name (required)
Shipping Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Email address (required)

Cell
Phone TypePhone Number
MUSHROOM SUPPLEMENTS via Jing Tang
Please choose one if applicable

Immunoshroom 6 (Reishi, Turkeys Tail, Shiitake, Maitake, Chage, Cordyceps) Capsules
Immunoshroom 6 (Reishi, Turkeys Tail, Shiitake, Maitake, Chage, Cordyceps) Powder
Triobalancer 100 Organic Mushroom Blend (Lions Mane, Cordyceps, Reishi) Capsules
Triobalancer 100 Organic Mushroom Blend (Lions Mane, Cordyceps, Reishi) Powder


To request additional mushroom blends please list in box below

Please check box if you would like additional information emailed to you regarding Mushroom Supplements
NUTRIHERB SUPPLEMENTS via Jing Tang (combination of Western Neutraceuticals & Chinese Herbs)
Please choose one if applicable

Bright Mind Capsules
Bright Mind Powder
Canine Antioxidant
Heart Support
Joint Support Capsules
Joint Support Powder


To request additional Nutriherb blends please list in box below

Please check box if you would like additional information emailed to you regarding Nutriherb Supplements
JING TANG HERBAL REFILL ONE
Name of Pet-Patient

Name of Herbal refill request :
Strength of blend requested above :
Current dose being given to patient :
Please use this space to provide additional patient dosing updates or questions for Dr. Brown

JING TANG HERBAL REFILL TWO
Name of Pet-Patient

Name of Herbal refill request :
Strength of blend requested above :
JING TANG HERBAL REFILL THREE
Name of Pet-Patient

Name of herbal refill request :
Strenght of herbal requested above :
JING TANG HERBAL REFILL FOUR
Name of Pet Patient

Name of herbal refill request :
Strength of blend requested above :
JING TANG HERBAL REFILL FIVE
Name of Pet Patient

Name of herbal refill request :
Strength of herbal requested above :
JING TANG HERBAL REFILL SIX
Name of Pet Patient

Name of herbal refill request :
Strength of herbal requested above :
Please list current dosing being given to patient (s) or questions for Dr. Brown. Thank you

Preferred Payment Method (required)

Paypal invoice
Zelle
Venmo



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