New Client Request Form

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

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New Client & Patient Request

paw icon Brown Veterinary Housecalls paw icon 


stethoscope icon GENERAL MEDICINE HOUSECALL REQUEST FORM

Sick/Injured/Nonemergency

This appointment choice offers General Medicine Service & Treatment options for Dogs & Cats  such as Comprehensive Physical Exams for nonemergency health concerns, Lab Services, Prescription Medication & more. Additional fees apply for adjunct/a la carte services, extended time/travel, etc. 

Please note this is a general medicine appointment only. TCVM (Acupuncture) not available with this choice. 

ONE HEALTH CONCERN PER APPOINTMENT

arrow icon Return to New Client Resource Page


NEW CLIENT REQUEST FORM-SICK

Please tell us which website you used to access this form as Dr. Brown has three branches to her practice (required)

Brown Veterinary Housecalls: Brownvetservices.com
Soul Puppy Holistic Healing: Soulpuppy.net
Equine Acupuncture-TCVM: Drbrownequineacupuncture.com


Correct Form Confirmation (required)

My pet has current health concerns that I wish to address with a General Medicine Housecall. I understand this is not an Integrative or TCVM appointment-please proceed
I am not interested in General Medicine-please stop and review other options on new client resource page


Owner Verification
Owner Verification (required)

I am 18 years or older, the rightful owner of the pets listed below, responsible for medical decisions and financial payment of services rendered, who will be present for the appointment if the request is approved
I am submitting this form on behalf of an elderly family member or disabled person & will list contact information FOR ALL PERSONS INVOLVED & will give more details in dialogue box below


Additional Information if submitting this form for an elderly family member or disabled person

Aggressive Pet Policy
Temperament Disclosure (required)

My pet has a history of aggression and needs to be sedated with injectable medication in order to be examined or treated-PLEASE STOP HERE
Injectable Sedation has been recommended by my regular vet for my pet in order to be examined or treated-PLEASE STOP HERE
My pet has Fear Aggression-I understand my pet may be accepted under terms of probation or not at all pending review
My pet is a Fear Biter-I understand my pet may be accepted on probation or not at all pending review
My pet has no temperament concerns that I am aware of


Additional Information regarding your pets temperament

General Medicine-Medical (wellness & TCVM not included)
General Medicine-Medicial Housecall: Includes up to One Hour Total Appointment Time (dogs/cats). Additional Fees Apply for Adjunct/A la Carte Services, extended time/travel. (required)

Sick/Injured/Nonemergency General Medicine-Medical Housecall (one health concern per request please)- Exam/Consult/Base Travel-starts at $222


Primary Owner Name (required)
First Name (required)
Last Name (required)
Spouse or Secondary Owner Name
First Name
Last Name
Address-please list one location only (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Major Cross Streets (required)

Complex or Community Name

Building Number or Letter

Apartment or Unit Number or Letter

Gate Code if applicable

Horse Barn or Stable Address and Name

Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone
Phone TypePhone Number
Email
Email address (required)

Pet Information
Pet #1 Name (required)

Type of Pet (required)

Canine
Feline
Equine


Age: Years, Months

Breed:

Color

Sex:

Male
Female


Neutered/Spayed

Intact
Neutered
Spayed


Is your pet current on vaccines?

Yes
No
Not sure
Rabies only
I no longer vaccinate my pet
My pet has never been vaccinated
I prefer vaccine titers


Does your pet have a history of vaccine reactions?

Yes
No
Not sure


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

Yes
No
My pet has never had labwork


Reason for appointment/main concerns (One health concern per request please) (required)

Duration of above concerns/conditions

Goals of appointment/treatment? (One health concern per request please) (required)

Please list any history of chronic medical conditions.

Please list any previous surgery or dental procedures along with approx age or year of last procedure

My pet eats the following diet

Commercial diet
Raw diet
Homecooked diet
Hay
Other


If your pet on Heartworm prevention?

Yes
No
Not applicable
What is heartworm?


Is your pet on flea/tick prevention?

Yes
No


Please list all medications your pet is currently taking

Please list any herbs, supplements, CBD/Hemp etc that your pet is currently taking

Does your pet have a history of valley fever?

Yes
No
Never been tested
Currently being treated
What is valley fever?


My Pets behavior at vet clinics (required)

My pet needs to be muzzled at the vet office in order to be examined or treated
My pet is always muzzed at the vet office as a precaution
My pet may need to be muzzled
My pet does best in the exam room with me
My pet does best when taken out of the exam room away from me
My pet takes oral medication prior to vet visits
Oral medication taken prior to vet visits has been recommeded for my pet
My pet has no temperament concerns that I am aware of


Does your pet have a history of anxiety? (required)

My pet is taking behavior modification prescription medication
My pet is working with a board certified behavorialist
My pet is working with a trainer
My pet has firework anxiety
My pet has storm phobia
I think my pet may have anxiety
My pet has anxiety that is not the same as Fear Aggression or Fear Biting
My pet has separation anxiety
My pet does not have a history of anxiety to the best of my knowledge


Current/Previous Veterinary Practice

Phone number or City and State of previous vet.

Special requests or conditions?

How did you hear about our services?

Referral
Ad
Newspaper
Facebook
Instagram
Other
Internet search
Nextdoor
Google
Event
Rescue
Cozy Couch Directory
Local Vet Clinic
My pets veterinarian


If referred by an individual, who may we thank for the referral?

Additional Pet Information
Pet #2 Name

Type of Pet

Canine
Feline
Equine


Additional Pet Information
Pet #3 Name

Type of Pet

Canine
Feline


NATURE OF SERVICE

Dr. Brown sees patients by scheduled appointment only during regular business hours based on location and availability. Please note this is not an emergency, on-call or overall concierge service. Due to the nature of this service and territory covered, it is recommended that all pet owners be familiar with local vets and emergency clinics in their area should the need arise. Concierge service options available via paid membership packages on a case by case basis pending availability. Soul Puppy is a TCVM specialty office and is not a full service clinic.
DEPOSITS/PAYMENTS/CANCELLATION POLICIES

A minimum deposit of $50 per pet is required to confirm all appointments which will be deducted from the invoice total (for approved requests only notified via email). Payment is due at time of services rendered via cash, credit card, zelle or venmo. There is a $25 48 h notice cancellation fee, $50 24 hour notice cancellation fee, $100 same day cancellation fee if less than 12 hours notice (prepaid acupuncture packages automatically forfeit a treatment visit) and a $200 minimum no show/not home fee including forfeit of any prepaid urgent care/emergency/extended travel fees & deposits (prepaid acupuncture packages automatically forfeit a treatment visit).
AGGRESSIVE PET POLICY

For safety purposes Dr. Brown has a no aggressive pet policy. She reserves the right to decline a physical exam if a pet displays aggressive behavior, such as growling, snarling, lunging or attempting to bite. If the pet is deemed to be aggressive by the veterinarian, the client agrees to pay in full, the house call and travel fee and a veterinarian consultation fee. Dr. Brown does not accept pets with a history of aggression or in need of sedation for exams. Dr. Brown reserves the right to refuse service at her discretion.
CLIENT POLICY

Dr. Brown and staff are happy to assist you and your pet in a mutually enjoyable and respectful working relationship with healthy boundaries as outlined on this website. Dr. Brown is a proud supporter of NOTONEMOREVET and reserves the right to refuse service at her discretion.
DIRECT CORRESPONDENCE WITH DR. BROWN

Direct correspondence with Dr. Brown is available via In Person Appointments, TeLeVET Time Remote Support Services & Concierge Package Services. TeLeVET fees apply after initial complimentary follow up per In Person Appointment. Please note unlimited direct correspondence with Dr. Brown via email/phone/text is not included once an appointment has ended. Please request TeLeVET Time for continued support. Online forms & email is the preferred method of communication due to the nature of this practice. Active clients will receive a private number for complimentary text scheduling. This number is for scheduling purposes only (no medical texts please). Thank you
PRACTICED POLICY AGREEMENT
I have read the Deposit/Payment/Cancellation, Nature of Service, Correspondence with Dr. Brown, Aggressive Pet and Client Policy and agree to the terms. (required)

I Agree
I Disagree


I understand that I will receive an email from scheduling@brownvetservices.com regarding my appointment request within 1 to 3 business days otherwise this form did not process correctly and we did not receive it. All required fields must be entered.
I understand I must contact my current/previous veterinarian directly and have my pet(s) medical records & vaccine history emailed to records@brownvetservices.com for review. Please note requests are waitlisted until records received.
IMPORTANT: Submitting this form completes step one (new client form). Please immediately go to step two (medical records). Requests are wait listed until medical records (step two) are received for review. Please respond to our emails for best service.
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