TeLEVET Time Remote Support Request

BROWN VETERINARY

HOUSECALLS

Valley Wide

EQUINE

MOBILE ACUPUNCTURE

Valley Wide

SOUL PUPPY

HOLISTIC HEALING

Downtown Mesa

BROWN VETERINARY HOUSECALLS

Local-Small Business-Private Practice

Colleen Brown DVM

No Emergencies

EMERGENCY RESOURCES

#notonemorevet

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

Active Client Communication & Support Request Form

Doctor with Cat and hart icon for televet time

TeLeVET Fees apply

TeleVet Request Active Patient

ACTIVE VCPR REQUIRED TO PROCEED: By checking this box I confirm that my pet is an active patient of Dr. Brown (VCPR=in person exam within last 12 months)

My pet is an active patient via

Brown Veterinary Housecalls
Mobile Equine Acupuncture
Soul Puppy Holistic Healing

Name

First Name	Last Name

Phone
Phone Type	Phone Number

Email Address

Pets Name

Please list current diet and all medications/supplements your pet is currently taking (required)

This condition or concern is (required)

New
Chronic
Unsure

Brief overview of main concerns or questions. (required)

My pet is (required)

Eating normally
Eating less
Not eating

My pet has (required)

Vomiting
Diarrhea
Normal stools
Vomiting & Diarrhea

My pets activity is (required)

Normal
Lethargic
Decreased

My pet is (required)

Breathing normally
Coughing
Sneezing

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

Additional Space if needed.

If this is a third party communication request for Dr.Brown to speak with specialist, trainer, etc regarding an active patient or to review documents provided by third party, please list name and contact information with authorization below

Third Party Contact Info, Authorization and Release

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

Have additional records or pictures been submitted via email to records@brownvetservices.com or text?

Yes
No

By checking this box I understand this is not an emergency response service

By checking this box I understand Dr. Brown bills for her remote time and expertise in 15 min increments at current TeLeVET Time hours and rates (subject to change without notice)

By checking this box I agree to PREPAY for the first 15 min as chosen below along with any additional time invoiced

Response Options (email only) (required)

Virtual Office Hour Fridays-$44/15min
Same Business Day (Tues, Wed, Thurs only) $88/15min
Saturday-Closed: Afterhour request at $125/15min
Monday-Closed: Afterhour request at $125/15min
Sunday-Closed: Service Unavailable

PRE-PAYMENT REQUIRED: Options (for ACTIVE patients only-any payment received from NONCLIENTS will be CHARGED a transaction and return fee) (required)

Zelle via 480-494-6034 or brownvethc@gmail.com
Paypal Direct via drbrown@brownvetservices.com
Venmo via @brownvethousecalls

By checking this box I understand that if my pets condition can not be addressed or worsens that I must schedule an in person 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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Thank you for your referrals!

Family owned & operated since 2010