New Client Form

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

New Client-Patient Request Form

Thank you for choosing Brown Veterinary Services for your pet care needs! 

Step One 

  • Submit new client request form below 
    • This form will automatically be emailed to Dr. Brown when completed. All required fields must be filled. A confirmation window will pop up immediately when submitted correctly
    • IMPORTANT: If you do not receive a confirmation window immediately and email from Dr. Brown within 1 business day then the form did not process correctly and your request was not received

Step Two

  • Review Process
    • Dr. Brown will review information submitted from steps one and two and send email regarding appointment request
    • For safety purposes, Dr. Brown does not accept patients with a history of aggression or in need of sedation for exams

Step Three 

  • Submit appointment deposit of $50 via zelle or paypal after receiving appointment request approval via email by Dr. Brown.
  • Note: Submitting a deposit before or without appointment approval will not guarantee an appointment 

Step Four

  • Appointment date/time confirmation email
  • Thank you for adhering to COVID-19 guidelines. Masks required for all appointments
  • 24 hour cancellation/no show fee of $50 

Step Five

Please note this is not an emergency, on call or concierge service.

  • Patients are seen by scheduled appointments only.
  • Regular business hours are Mon-Fri 9AM to 6PM. Appointment hours vary based on availability and location. 
  • If you have an EMERGENCY, please contact the nearest emergency clinic in your area, or call VCA Animal Referral and Emergency Center at 480-898-0001.
  • Examples of emergencies may consist of, but are not limited to, labored breathing, bleeding, active seizure, broken limbs, hit by car, dog fight/open wounds, males cats unable to urinate, etc.
  • If your pet is deceased please contact PALS directly

~Thank you, Dr. Brown 

 

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, Gate Code, etc.

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

Appointment Type
Selection (required)

Housecall-Western Veterinary Medicine only-Wellness/Prevention/Vaccines, etc
Housecall-Western Veterinary Medicine only-Sick/Injured (nonemergency)
Housecall-Integrative Veterinary Medicine (both Western/TCVM)-please see extended Time & Fee Specifications
Housecall-TCVM only (Acupuncture, Herbal, Food Therapy)
Housecall-Quality of Life-In Home Gentle Euthanasia & Cremation Services
Equine Acupuncture & Chinese Veterinary Medicine for Horses-Housecall or Barncall
Soul Puppy Holistic Healing-Mesa TCVM only office
Telemedicine (Not currently available)


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


Are your pets vaccines current?

Yes
No
Unknown


Do you have your pet(s) medical records?

Yes
No


Please have your pet(s) medical records emailed to brownvethc@gmail.com after submitting this form
By clicking yes, I agree to have my pet(s) medical records and vaccine history emailed for review
Name of Current/Previous Veterinary Practice

Phone number or City and State of previous vet.

I understand that Dr. Brown will contact me via email after receiving this form
Reasons or conditions that prompted your visit? (required)

Special requests or conditions?

How did you hear about our services?

Referral
Ad
Newspaper
Tv
Facebook
Instagram
Other


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
Nature of Service
Thank you for choosing us for your pet care needs. Dr. Brown sees patienst by scheduled based on location and availability. Brown Veterinary Housecalls is not an emergency, on-call or 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.
Payment is due at time of services rendered by cash or credit card. A $50 deposit is required to hold all new client appointments. There is a 24 hour $50 cancellation fee.
Aggressive Pet Policy
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.
I have read Payment Policy, Cancellation Policy, Nature of Service and Aggressive Pet Policy and agree to the terms. (required)

I Agree
I Disagree


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