Telemedicine Request Form

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

Telemedicine Request Form -via email for active patients only. 

Brown Veterinary Services understands that a housecall or appointment may not always be available or feasible for multiple reasons either due to Covid-19, the logistics of scheduling, busy lifestyles, etc. As Dr. Brown is typically with a patient or traveling for a housecall, telemedicine responses can take up to 3 business days. Urgent 24 h response upgrades are available for an additional fee with weekday or weekend options. Please request an appointment or go to the nearest full service or emergency clinic should your pets condition deteriorate. Thank you. 

Telemedicine Request

Name
First Name
Last Name
Phone
Phone TypePhone Number
Email Address

Pets Name

Please list current diet and all medications/supplements
Is this a new condition or concern? :
Is this a chronic condition or concern? :
Brief overview of main concerns or questions.

Please use this for additional space if needed. Be sure to include when concerns started.

Additional Space if needed.

Have additional records or pictures been emailed for review to brownvethc@gmail.com :
Please choose from the following telemedicine options

New condition $155
Chronic condition 1 question $55
Chronic condition up to 3 questions $82
Chronic condition more than 3 questions $125


By checking this box I understand Dr. Brown will respond to my questions via email within 3 business days
By checking this box I would like to pay an additional $75 for an urgent response within 24 hours (weekdays only) in addition to regular telemedicine fees. If weekend (Sat/Sun) involved must click weekend option instead.
By checking this box I would like to pay an additional $100 for an urgent response within 24 hours (weekend-Sat/Sun) in addition to regular telemedicine fees.
By checking this box I understand that I must prepay for telemedicine services via zelle or paypal.
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 appointment or go to the nearest full service veterinary clinic or emergency clinic
Preferred payment options . If choosing Zelle please send funds to cell at 480-494-6034 or email at brownvethc@gmail.com :
Thank you for choosing Brown Veterinary Services for your pet care needs.


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