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 Support & Direct Communication with Dr. Brown Outside of In-Person Appointments

FOR ACTIVE PATIENTS ONLY

TeLeVET fees & restrictions apply

LEARN MORE

TeleVet Request Active Patient

Active Patient Status Confirmation (required)

The pet for which this form is being submitted is an active patient who has had an in person exam with Dr. Brown within 12 months-PLEASE PROCEED
I am an active client however the pet for which this form is being submitted has not had an in person exam with Dr. Brown within the last 12 months-STOP AND SUBMIT AN APPOINTMENT REQUEST FORM PLEASE
My pet is NOT an active patient nor am I an active client of Dr. Brown-STOP AND SUBMIT NEW CLIENT REQUEST FORM PLEASE. NOTE: THIS SERVICE IS FOR ACTIVE PATIENTS ONLY. CONTINUING TO SUBMIT THIS FORM IF YOU ARE NOT A CLIENT & DR. BROWN HAS NEVER SEEN YOUR PET WILL RESULT IN THIS FORM BEING DELETED WITHOUT A RESPONSE. THANK YOU

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-if new this request may be converted to a telehealth or telemedicine consult (pending new Arizona legislation start date only) or an in person appointment may be recommended-additional fees apply
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 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. 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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