Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

New Client & Patient Request Form

Brown Veterinary Housecalls Soul Puppy Holistic Healing Equine Mobile Specialty Services

KEY

(Click icons for more info)

GENERAL MEDICINE HOUSECALL: Exams, vaccines/titers, labwork & prescription medication service options, etc. TCVM not included

TRADITIONAL CHINESE VETERINARY MEDICINE (TCVM) HOUSECALL: Acupuncture, Chinese Herbal Medicine, TCVM Food Therapy options. General Medicine not included

INTEGRATIVE HOUSECALL: Combination of both General Medicine & TCVM Service & Treatment options during same appointment

IN HOME EUTHANASIA & CREMATION HOUSECALL, QUALITY OF LIFE-SECOND OPINION HOUSECALL

EQUINE MOBILE TCVM HOUSECALL: Acupuncture, Chinese Herbal Medicine, TCVM Food Therapy options for horses

SOUL PUPPY HOLISTIC HEALING: Downtown Mesa Traditional Chinese Veterinary Medicine (TCVM) only specialty office for dogs & cats (Acupuncture, Herbal, Food Therapy treatment options). This is an acupuncture practice. All patients are treated with acupuncture. This is not a housecall. General Medicine not available at this location

TRAVEL AREA

PLEASE COMPLETE THE FIRST TWO STEPS & AWAIT FURTHER INSTRUCTION VIA EMAIL CORRESPONDENCE

Step One: ONLINE NEW CLIENT REQUEST FORM SUBMISSION

Please submit the online NEW CLIENT REQUEST FORM below then immediately go to step two

An email from scheduling@brownvetservices.com will be sent no later than 1 to 3 business days acknowledging receipt of form if form processed correctly. All required fields must be filled for form to process correctly. If you do not receive an email within 1 to 3 business days it means we did not receive your form. Please email scheduling@brownvetservices.com to let us know a form had been submitted & include the type of device and browser used for tech support

Please respond to emails for best service to keep your request active as we are either with a patient or traveling. Failure to respond to emails and follow new client request protocol in order as directed will deactivate request. See FAQ for additional info

Step Two: MEDICAL RECORD HISTORY RELEASE & SUBMISSION

Immediately after submitting the online request form please contact your current/previous veterinary hospital(s) directly to release your pets medical record history including rabies vaccine history to be emailed directly from veterinary clinic(s) to records@brownvetservices.com.

Please do not send copies of receipts as they are not the same as medical records.

Requests are waitlisted until medical records are received for review for safety purposes

If you do not receive a status update email regarding your request it means we have not received medical records

ZERO TOLERANCE AGGRESSIVE PET & SEDATION POLICY

APPOINTMENT POLICIES

Step Three: DEPOSIT FOR APPROVED REQUESTS ONLY THAT HAVE BEEN OFFICIALLY NOTIFIED VIA EMAIL

A minimum deposit of $50 per pet for approved requests only is required prior to scheduling which will be deducted from invoice total. If applicable, any urgent care, after hours or additional/extended travel fees are to paid along with the deposit. Approved requests are waitlisted until deposit received. Please do not submit a deposit unless you receive an email that your request has been approved. Unauthorized deposits received are subject to fees/forfeit if request not approved

FINANCIAL POLICIES

Step Four: APPOINTMENT DETAILS OFFERED & CONFIRMED

Once the appointment deposit is received for approved requests, the soonest available appointment dates and times based on location & availability will be offered & held for 24 hours only before being offered to the next patient on the waitlist. Once an appointment date/time is chosen a confirmation email will be sent.

Please respond in a timely manner as a courtesy to Dr. Brown & other patients. Dr. Brown is limited in the number of patients she can see daily due to the nature of this mobile & specialty practice. The above protocol can easily be completed same day by following the steps & responding to emails. Failure to respond in a timely manner will result in refund of deposit & permanent cancellation of request. Dr. Brown reserves the right to refuse service at her discretion. Thank you

CANCELLATION POLICIES

Thank you for choosing Dr. Brown for your pets healing needs!

Return to New Client Resource Page

NEW CLIENT REQUEST FORM

Please tell us which website you used to access this form as Dr. Brown has three branches to her practice (required)

Brown Veterinary Housecalls: Brownvetservices.com
Soul Puppy Holistic Healing: Soulpuppy.net
Equine Acupuncture-TCVM: Drbrownequineacupuncture.com

THIS FORM CAN ONLY BE SUBMITTED BY RIGHTFUL OWNERS WHO MUST BE PRESENT AT TIME OF APPROVED APPOINTMENT REQUESTS

Owner Verification (required)

I am 18 years or older, the rightful owner of the pets listed below, responsible for medical decisions and financial payment of services rendered, who will be present for the appointment if the request is approved
I am submitting this form on behalf of an elderly family member or disabled person & will list contact information FOR ALL PERSONS INVOLVED & will give more details in dialogue box below

Additional Information if submitting this form for an elderly family member or disabled person

ZERO TOLERANCE AGGRESSIVE PET & SEDATION POLICY (please note for safety purposes Dr. Brown does not accept pets with a history of aggression or in need of sedation for exams)

Temperament Disclosure (required)

My pet has a history of aggression and/or a history of needing to be sedated with injectable medication in order to be examined or treated-PLEASE STOP HERE
Injectable Sedation has been recommended by my regular vet for my pet in order to be examined or treated-PLEASE STOP HERE
My pet has Fear Aggression-I understand my pet may be accepted under terms of probation or not at all pending review
My pet is a Fear Biter-I understand my pet may be accepted on probation or not at all pending review
My pet is taking SSRI medication for aggression or anxiety-I understand my pet my be accepted on probation or not at all pending review
My pet has no temperament concerns that I am aware of

Additional Information regarding your pets temperament

PLEASE CAREFULLY REVIEW ALL APPOINTMENT OPTION CATEGORIES BELOW & CHOOSE ONLY ONE

INTEGRATIVE HOUSECALL OPTIONS

Housecall Choices for INTEGRATIVE VETERINARY MEDICINE -BOTH GENERAL MEDICINE & TCVM Service Options during same appointment-Up to Two Hours of Total Appointment Time (dogs/cats). Additional Fees apply for adjunct services

INTEGRATIVE SPECIALTY HOUSECALL-EXAM/CONSULT/BASE TRAVEL w/ ACUPUNCTURE-starts at $495
INTEGRATIVE SPECIALTY HOUSECALL- EXAM/CONSULT/BASE TRAVEL w/ ACUPUNCTURE & CHINESE HERBAL MEDICINE-starts at $650
INTEGRATIVE SPECIALTY HOUSECALL-EXAM/CONSULT/BASE TRAVEL W/ ACUPUNTURE, HERBAL & BASIC FOOD THERAPY-starts at $700

TRADITIONAL CHINESE VETERINARY MEDICINE HOUSECALL OPTIONS

Housecall Choices for TRADITIONAL CHINESE VETERINARY MEDICINE (TCVM) Only Service Options- Up to One Hour Total Appointment Time (dogs/cats). General Medicine not available with the choice. Additional fees apply to a la carte services

TCVM SPECIFIC HOUSECALL-EXAM/CONSULT/BASE TRAVEL w/ ACUPUNCTURE -starts at $330
TCVM SPECIFIC HOUSECALL-EXAM/CONSULT/BASE TRAVEL w/ ACUPUNCTURE & CHINESE HERBAL MEDICINE -starts at $510
TCVM SPECIFIC HOUSECALL-EXAM/CONSULT/BASE TRAVEL W/ ACUPUNCTURE, HERBAL & BASIC FOOD THERAPY-starts at $560

EQUINE HOUSECALL OR BARNCALL OPTIONS

Housecall Choices for EQUINE TRADITIONAL CHINESE VETERNARY MEDICINE (TCVM) Only Service Options (horses). General Medicine not available with this choice

EQUINE TCVM SPECIFIC HOUSECALL- EXAM/CONSULT/BASE TRAVEL w/ ACUPUNCTURE-starts at $350
EQUINE TCVM SPECIFIC HOUSECALL- EXAM/CONSULT/BASE TRAVEL w/ ACUPUNCTURE & CHINESE HERBAL MEDICINE-starts at $530
EQUINE TCVM SPECIFIC HOUSECALL-EXAM/CONSULT/BASE TRAVEL W/ ACPUNCTURE, HERBAL & BASIC FOOD THERAPY-starts at $580

GENERAL MEDICINE HOUSECALL OPTIONS (DOES NOT INCLUDE ACUPUNTURE OR HOLISTIC TCVM OPTIONS)

Housecall Choices for GENERAL MEDICINE ONLY Service Options-Up to One Hour Total Appointment Time (dogs/cats). Additional Fees Apply for Adjunct Services. TCVM is not available with this choice

WELLNESS & PREVENTION GENERAL MEDICINE HOUSECALL (no health concerns)- EXAM/CONSULT/BASE TRAVEL-starts at $199
SICK/INJURED/NONEMERGENCY GENERAL MEDICINE HOUSECALL (health concerns)- EXAM/CONSULT/BASE TRAVEL-starts at $222

END OF LIFE SERVICE HOUSECALL OPTIONS

Housecall Choices for QUALITY OF LIFE ASSESSMENT/Second Opinions or IN HOME GENTLE EUTHANASIA WITH CREMATION Service Options-Up to One Hour Total Appointment Time (dogs/cats)

QUALITY OF LIFE ASSESSMENT /SECOND OPINION HOUSECALL- GENERAL MEDICINE ONLY EXAM/CONSULT/BASE TRAVEL-starts at $199
IN HOME GENTLE EUTHANASIA WITH CREMATION HOUSECALL-variable based on weight/type of cremation

SOUL PUPPLY HOLISTIC HEALING (MESA TCVM SPECIALTY OFFICE) APPOINTMENT OPTIONS. PLEASE NOTE: THIS IS NOT A HOUSECALL (SOUL PUPPY PATIENTS ARE NOT CONSIDERED HOUSECALL PATIENTS AND VICE VERSA)

SOUL PUPPY HOLISTIC HEALING Choices (DOWNTOWN MESA TCVM-ONLY SPECIALTY PRIVATE PRACTICE LOCATION) Appointment Service Options-Up to One Hour Total Appointment Time (dogs/cats) Note: this is not a housecall or a full service clinic i.e. No General Medicine

SOUL PUPPY HOLISTIC HEALING MESA OFFICE w/ ACUPUNCTURE-starts at $237
SOUL PUPPY HOLISTIC HEALING MESA OFFICE w/ ACUPUNCTURE & CHINESE HERBAL MEDICINE-starts at $417
SOUL PUPPY HOLISTIC HEALING MESA OFFICE W/ ACUPUNCTURE, HERBAL & BASIC FOOD THERAPY-starts at $467

APPOINTMENT CHOICE CONFIRMATION

Please confirm your appointment choice above by choosing the matching option below (required)

Integrative Housecall with Acupuncture
Integrative Housecall with Acupuncture & Herbal
Integrative Housecall with Acupuncture, Herbal & Basic Food Therapy
TCVM Housecall with Acupuncture
TCVM Housecall with Acupuncture & Herbal
TCVM Housecall with Acupuncture, Herbal & Basic Food Therapy
Equine Acupuncture Housecall
Equine Acupuncture Housecall with Herbal
Equine Acupuncture Housecall with Herbal & Basic Food Therapy
Housecall General Medicine-Wellness & Prevention (no health concerns)-DOES NOT INCLUDE HOLISTIC TCVM OPTIONS
Housecall General Medicine-Sick/Injured/Nonemergency (health concerns)-DOES NOT INCLUDE HOLISTIC TCVM OPTIONS
Quality of Life Assessment/Second Opinion-General Medicine Housecall
In Home Euthanasia & Cremation
Soul Puppy Holistic Healing Mesa Office with Acupuncture
Soul Puppy Holistic Healing Mesa Office with Acupuncture & Herbal
Soul Puppy Holistic Healing Mesa Office with Acupuncture, Herbal & Basic Food Therapy

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 (required)

Complex or Community Name

Building Number or Letter

Apartment or Unit Number or Letter

Gate Code if applicable

Horse Barn or Stable Address and Name

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone
Phone Type	Phone Number

Email address (required)

Pet Information

Pet #1 Name (required)

Type of Pet (required)

Canine
Feline
Equine

Age: Years, Months

Breed:

If mixed breed was written above please describe your pet and what breed it most resembles

Please list your dog or cats approximate weight in pounds and/or size i.e. small dog, medium size dog, large breed dog, giant breed, etc

Color

Sex:

Male
Female

Neutered/Spayed

Intact
Neutered
Spayed
Mare
Gelding
Stallion

Is your pet current on vaccines?

Yes
No
Not sure
Rabies only
I no longer vaccinate my pet
My pet has never been vaccinated
I prefer vaccine titers

Does your pet have a history of vaccine reactions?

Yes
No
Not sure

Has your pet had a full blood panel in the past 12 months?

Yes
No
My pet has never had labwork

Reason for appointment/main concerns (required)

Duration of above concerns/conditions

Goals of appointment/treatment? (required)

Please list any history of chronic medical conditions.

Please list any previous surgery or dental procedures along with approx age or year of last procedure

My pet eats the following diet

Commercial diet
Raw diet
Homecooked diet
Hay
Other

If your pet on Heartworm prevention?

Yes
No
Not applicable
What is heartworm?

Is your pet on flea/tick prevention?

Yes
No

Please list all medications your pet is currently taking

Please list any herbs, supplements, CBD/Hemp etc that your pet is currently taking

Does your pet have a history of valley fever?

Yes
No
Never been tested
Currently being treated
What is valley fever?

My Pets behavior at vet clinics (required)

My pet needs to be muzzled at the vet office in order to be examined or treated
My pet is always muzzed at the vet office as a precaution
My pet may need to be muzzled
My pet does best in the exam room with me
My pet does best when taken out of the exam room away from me
My pet takes oral medication prior to vet visits
Oral medication taken prior to vet visits has been recommeded for my pet
My pet has no temperament concerns that I am aware of

Does your pet have a history of anxiety? (required)

My pet is taking behavior modification prescription medication
My pet is working with a board certified behavorialist
My pet is working with a trainer
My pet has firework anxiety
My pet has storm phobia
I think my pet may have anxiety
My pet has anxiety that is not the same as Fear Aggression or Fear Biting
My pet has separation anxiety
My pet does not have a history of anxiety to the best of my knowledge

Current/Previous Veterinary Practice

Phone number or City and State of previous vet.

Special requests or conditions?

How did you hear about our services?

Referral
Ad
Newspaper
Facebook
Instagram
Other
Internet search
Nextdoor
Google
Event
Rescue
Cozy Couch Directory
Local Vet Clinic
My pets veterinarian

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

Dr. Brown sees patients by scheduled appointment only during regular business hours based on location and availability. Please note this is not an emergency, on-call or overall 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. Concierge service options available via paid membership packages on a case by case basis pending availability. Soul Puppy is a TCVM specialty office and is not a full service clinic.

DEPOSITS/PAYMENTS/CANCELLATION POLICIES

A minimum deposit of $50 per pet is required to confirm all appointments which will be deducted from the invoice total. Payment is due at time of services rendered via cash, credit card, zelle or venmo. There is a $50 48 h notice cancellation fee, $75 24 hour notice cancellation fee, $125 same day cancellation fee if less than 12 hours notice (prepaid acupuncture packages automatically forfeit a treatment visit) and a $200 minimum no show/not home fee including forfeit of any prepaid urgent care/emergency/extended travel fees & deposits (prepaid acupuncture packages automatically forfeit a treatment visit).

AGGRESSIVE PET POLICY

For safety purposes Dr. Brown 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. Dr. Brown does not accept pets with a history of aggression or in need of sedation for exams. Dr. Brown reserves the right to refuse service at her discretion.

CLIENT POLICY

Dr. Brown and staff are happy to assist you and your pet in a mutually enjoyable and respectful working relationship with healthy boundaries as outlined on this website. Dr. Brown is a proud supporter of NOTONEMOREVET and reserves the right to refuse service at her discretion.

DIRECT CORRESPONDENCE WITH DR. BROWN

Direct correspondence with Dr. Brown is available via In Person Appointments, TeLeVET Time Remote Support Services & Concierge Package Services. TeLeVET fees apply after initial complimentary follow up per In Person Appointment. Please note unlimited direct correspondence with Dr. Brown via email/phone/text is not included once an appointment has ended. Please request TeLeVET Time for continued support. Online forms & email is the preferred method of communication due to the nature of this practice. Active clients will receive a private number for complimentary text scheduling. This number is for scheduling purposes only (no medical texts please). Thank you

PRACTICED POLICY AGREEMENT

I have read the Deposit/Payment/Cancellation, Nature of Service, Correspondence with Dr. Brown, Aggressive Pet and Client Policy and agree to the terms. (required)

I Agree
I Disagree

I understand that I will receive an email from scheduling@brownvetservices.com regarding my appointment request within 1 to 3 business days otherwise this form did not process correctly and we did not receive it. All required fields must be entered.

I understand I must contact my current/previous veterinarian directly and have my pet(s) medical records & vaccine history emailed to records@brownvetservices.com for review. Please note requests are waitlisted until records received.

IMPORTANT: Submitting this form completes step one (new client form). Please immediately go to step two (medical records). Requests are wait listed until medical records (step two) are received for review. Please respond to our emails for best service.

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