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

Thank you for choosing us for your pet care needs!

TRAVEL AREA

Step One: FORM

Please submit the online NEW CLIENT REQUEST FORM below then immediately go to step two

Step Two: RECORDS

Please have your pets medical record history and rabies vaccine information emailed directly from current/previous veterinary clinics to records@brownvetservices.com-requests are waitlisted until records are received. Please do not send copies of receipts as those are not medical records. For safety purposes, Dr. Brown does not accept pets with a history of aggression or in need of sedation for exams & reserves the right to refuse service at her discretion

Step Three: DEPOSIT

A minimum deposit of $50 per pet for approved requests is required prior to scheduling which will be deducted from invoice total. If applicable, any urgent care, after hours or additional/extended travel fees are to paid along with the deposit-approved requests are waitlisted until deposit received

Step Four: APPOINTMENT CONFIRMATION

Once the appointment deposit is received for approved requests, available days and times will be offered and a confirmation email will be sent

IMPORTANT INFORMATION REGARDING NEW PATIENT REQUEST PROCESSING

New client forms are emailed directly to Dr. Brown from this site. You will receive an email from scheduling@brownvetservices.com no later than 1 to 3 business days if processed correctly. All required fields must be filled. If you do not receive an email within 1 to 3 business days it means we did not receive your form. Please email scheduling@brownvetservices.com to let us know if a form had been submitted. Please include the type of device and browser used for tech support if your form did not process correctly. Thank you! Please note this is not an EMERGENCY service.

HELPFUL FORM TIPS FOR APPOINTMENT CHOICE: Review Keys below, APPOINTMENT OPTIONS ,HELPFUL QUESTIONS ON NEW CLIENT PAGE or schedule a complimentary or prepaid CHAT for additional assistance as correct appointment choice is important for scheduling purposes.

We look forward to working with you and your beloved pet!

NEW CLIENT REQUEST FORM

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 Type	Phone Number (required)

Evening Phone
Phone Type	Phone Number

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
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 UTILIZE THE HELPFUL KEYS BELOW TO CHOOSE THE BEST APPOINTMENT OPTION FOR YOUR PETS HEALING NEEDS

Please Select One Appointment Option (required)

WELLNESS & PREVENTION HOUSECALL-starts at $185 (Basic-Western only)
SICK/INJURED/NONEMERGENCY HOUSECALL-starts at $185 (Basic-Western only)
GENERAL NONSPECIFIC EXAM/CONSULT MEET & GREET HOUSECALL-starts at $185 (Basic-Western only)
QUALITY OF LIFE ASSESSMENT/SECOND OPINION HOUSECALL-starts at $185 (Basic-Western only)
IN HOME GENTLE EUTHANASIA & CREMATION HOUSECALL-variable
TCVM w/ ACUPUNCTURE HOUSECALL-starts at $330 (Specialty-TCVM only)
INTEGRATIVE w/ ACUPUNCTURE HOUSECALL-starts at $495 (Specialty-both Western & TCVM)
EQUINE TCVM w/ ACUPUNCTURE HOUSECALL-starts at $350 (Specialty-TCVM only)
SOUL PUPPY HOLISTIC HEALING w/ ACUPUNCTURE DOWNTOWN MESA LOCATION -starts at $224 (Specialty-TCVM only office)

KEY: BASIC WESTERN HOUSECALL=Allopathic/Conventional Veterinary Medicine (i.e. comprehensive physical exam +/- options such as vaccines/titers, labwork, prescription medication, nail trims, ear cleaning, etc) Does not include acupuncture/TCVM

KEY: SPECIALTY TCVM HOUSECALL=Traditional Chinese Veterinary Medicine (i.e. Acupuncture +/- Herbal Medicine & TCVM Food Therapy options). Includes Acupuncture. Does not include Western Medicine

KEY: SPECIALTY INTEGRATIVE HOUSECALL=both Western & TCVM options during same appointment. Includes Acupuncture

KEY: MEET & GREET EXAM/CONSULT BASIC WESTERN HOUSECALL = designed for pet owners that wish to establish Dr. Brown as their Housecall Veterinarian and/or are unsure which appointment option to choose. Start here! Does not include acupuncture

KEY: QUALITY OF LIFE ASSESSMENT/SECOND OPINION BASIC WESTERN HOUSECALL- designed for pet owners not ready for euthanasia who would like to discuss hospice/palliative options or second opinions. Does not include acupuncture

KEY: SOUL PUPPY HOLISTIC HEALING= Downtown Mesa TCVM only SPECIALTY office for dogs & cats. Includes Acupuncture. Please note this is not a full service clinic/Western Medicine is not offered at this location

KEY: EQUINE=horses

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?

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

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. Payment is due at time of services rendered via cash, credit card, zelle or venmo. There is a $50 24 hour cancellation policy, $100 same day cancellation fee and a $100 minimum no show/not home fee.

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.

CONTACTING DR. BROWN

Due to the nature of this practice, Dr. Browns preferred method of contact is email as she is either actively with a patient or actively traveling for housecalls. Dr. Brown includes one supportive follow up email within one month of a patients appointment. TeleVet Time Service is available for continued correspondence and support outside of in person appointments. Dr. Brown charges an hourly rate for all remote services and correspondence outside of in person appointment time. 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 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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