TeleVet Request Form

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

TeleVET Time with Dr. B! Request Form

Remote Patient Care & Owner Support

Please use this form to access Dr. Browns heart-centered expertise outside of in-person appointments via remote email (preferred) or phone consults and correspondence.

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Dr. Brown bills for her time and expertise outside of in-person appointment time in 15 min increments at a rate of $50/15min.
- Excludes initial (complimentary) appointment follow up with each in-person exam
TeleVET Time correspondence is available for active patients only with a current in person exam by Dr. Brown within the last 12 months.
Response times vary during regular business hours (Tues-Fri 9to 5) and may take up to 1 to 3 business days for a response due to the nature of this practice.

Dr. Brown will always respond via email unless a phone call is necessary or requested.

IMPORTANT: Please request an in person appointment or go to the nearest full service or emergency clinic should your pets condition deteriorate.

TeleVet Request

Name

First Name	Last Name

Phone
Phone Type	Phone Number

Email Address

Pets Name

Please list current diet and all medications/supplements

This condition or concern is

New
Chronic
Unsure

Brief overview of main concerns or questions.

My pet is

Eating normally
Eating less
Not eating

My pet has

Vomiting
Diarrhea
Normal stools
Vomiting & Diarrhea

My pets activity is

Normal
Lethargic
Decreased

My pet is

Breathing normally
Coughing
Sneezing

Please use this for additional space if needed. Be sure to include when concerns started. The more detail the better.

Additional Space if needed.

Pictures and any new medical records or test results are very helpful

Have additional records or pictures been emailed for review to brownvethc@gmail.com

Yes
No

By checking this box I understand Dr. Brown will respond to my questions via email within 1 to 3 business days.

By checking this box I understand Dr. Brown bills for her time and expertise outside of in person appointment time in 15 minute increments at a rate of $50/15 min.

By checking this box I agree to prepay for the first 15 min. I also agree to pay for any additional time needed and invoiced.

Preferred payment options (required)

Zelle-send to 480-494-6034 or brownvethc@gmail.com
Paypal-send to drbrown@brownvetservices.com
Venmo-send to cmbrowndvm

By checking this box I understand that if my pets condition can not be addressed via telemedicine or worsens that I must schedule a housecall or Soul Puppy appointment or go to the nearest full service veterinary clinic or emergency clinic

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

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