New Client Form

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

New Client-Patient Request Form

for

Brown Veterinary Housecalls~Soul Puppy Holistic Healing~ Equine Mobile Specialty Services


Step One: Submit new client form 

Step Two- Have your pets veterinary medical records emailed to brownvethc@gmail.com directly from veterinary clinics/hospitals 

  • Dr. Brown will review information and her online assistant Deb will call or send email regarding appointment request 
  • For safety purposes, Dr. Brown does not accept pets with a history of aggression or in need of sedation for exams. 

Step Three- Submit minimum appointment deposit of $50 per pet via zelle, venmo or paypal after receiving appointment request approval by phone or email. Note: submitting a deposit before appointment approval will not guarantee an appointment. 


Step Four-Appointment date/time confirmation email 

  • Thank you for adhering to COVID-19 guidelines. Masks continue to be required for all appointments for safety purposes

Step Five- Review the how to prepare for your visit info on general housecall page and if applying for a multi-pet visit please also submit a patient history form for each additional pet listed. 


Additional Information: 

  • As Dr. Brown may not be available due to the nature of this service, it is recommended to be familiar with local veterinary and emergency clinics in your area. If your pet has a chronic internal medicine condition and/or is seeing Dr. Brown for TCVM only, please continue to keep an active client-patient relationship with your regular local veterinarian/full service clinic
  • Requests for same day appointments are subject to availability and may include an urgent care fee starting at $50 based on location and appointment needs, in addition to regular appointment fees. 
  • After hour appointment availability considered on a case by case basis pending doctor availability and includes after hour fees at doctor discretion. 
  • Phoenix is growing and many of the cities Dr. Brown travels to span great distances. Additional travel fees may apply based on individual location/address and travel time. 
  • Please note there is a 24 h $50 cancellation fee and no show fee starting at $100

EMERGENCIES:

It is not possible for Dr. Brown to be available for emergencies due to the nature of this practice. If you have an emergency please seek immediate care at the nearest pet emergency clinic in your area or call VCA Areca at 480-898-0001. Learn more about local emergency clinicsIf your pet is deceased please contact PALS directly for pick up and cremation services. 


We look forward to helping you with your beloved pets

Sincerely, Dr. Brown, Jim, Deb and Peanut! 


 

New Client

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

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)

Appointment Type Requested
Selection (required)

Housecall-Western Veterinary Medicine only-Wellness/Prevention/Vaccines, etc.- Starts at $185
Housecall-Western Veterinary Medicine only-Sick/Injured (nonemergency) -Starts at $185
Housecall-Integrative Veterinary Medicine (both Western/TCVM)-Starts at $395
Housecall-TCVM only (Acupuncture) -Starts at $295
Housecall-Quality of Life-In Home Gentle Euthanasia & Cremation Services -$Variable
Equine Acupuncture & Chinese Veterinary Medicine for Horses-Housecall or Barncall- Starts at $350
Soul Puppy Holistic Healing-Mesa TCVM only office (Acupuncture) -Starts at $187
TeleVet Time (active patients only) -Starts at $82/30min


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
Mare
Gelding
Stallion


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 (required)

Duration of above concerns/conditions

Goals of appointment/treatment? (required)

Please list any history of chronic conditions. For example: abnormal bloodwork, liver/kidney disease, heart murmur, seizures, colic, laminitis, navicular, etc

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?


Current/Previous Veterinary Practice

Phone number or City and State of previous vet.

By clicking yes, I agree to contact my current/previous veterinarian and have my pet(s) medical records and vaccine history emailed to Dr. Brown for review
I understand that Dr. Browns online assistant Deb will contact me via email or phone after receiving this form to discuss the next step in the appointment process.
Special requests or conditions?

How did you hear about our services?

Referral
Ad
Newspaper
Facebook
Instagram
Other
Internet search
Nextdoor
Google
Event
Rescue


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 is required to confirm all appointments which will be deducted from the invoice total. Payment is due at time of services rendered via cash, credit card, zelle or venmo. There is a $50 24 hour cancellation policy and a $100 minimum no show/not home fee.
AGGRESSIVE PET POLICY

Safety is important to Dr. Brown. Therefore she 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. By clicking "I Agree" in the section below, you are stating you agree to these terms.
CONTACTING DR. BROWN

Due to the nature of this practice, Dr. Browns preferred method of contact is email. Dr. Brown includes one supportive follow up email or phone call within one month of each appnt. For continued correspondence, support and veterinary care please request an appointment or paid phone or email consults and correspondence via TeleVet Time Services. Direct access to Dr. Brown is available via appointments, paid TeleVet Time or advanced concierge packages pending availability. Please note Dr. Brown does not respond to text or social media messages.
PRACTICED POLICY AGREEMENT
I have read the Deposit/Payment/Cancellation, Nature of Service, Contacting Dr. Brown and Aggressive Pet Policy and agree to the terms. (required)

I Agree
I Disagree


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