TeLEVET Time Remote Support Request

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

Doctor with Cat and hart icon for televet time

Request Form 

Post Appointment Communication & Support from Dr. Brown Outside of In-Person Appointments

FOR ACTIVE PATIENTS ONLY

TeLeVET fees & restrictions apply

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TeleVet Request Active Patient

Name
First Name
Last Name
Phone
Phone TypePhone Number
Email Address

Pets Name

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)
Please list current diet and all medications/supplements (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.

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, 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 or text?

Yes
No


By checking this box I understand Dr. Brown will respond to my questions within 12 to 24 hours via email (preferred), phone or text (if applicable) and that this is not an emergency response service
By checking this box I understand Dr. Brown bills for her time and expertise outside of in person appointment time in 15 min increments at current TeLeVET Time rate during regular business hours (additional after hours fees apply if applicable))
By checking this box I agree to PREPAY for the first 15 min at $44-$88/15min pending type of request. An additional $125/per 10 min is required if outside of regular business hours. I also agree to pay for any additional time needed and invoiced.
PREPAYMENT options (required)

Zelle
Paypal
Venmo


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!

 PROUD TO BE LOCALLY OWNED & OPERATED BY DR. BROWN

 

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Thank you for your referrals!

 PROUD TO BE LOCALLY OWNED & OPERATED BY DR. BROWN

 

TeLeVET Button

House Calls Button

Equine Acupuncture Button

Soul Puppy Holistic Healing Button

In Home Euthanasia button