Herbal Prescription Refill Form

BROWN VETERINARY

HOUSECALLS

Integrative Veterinary Medicine for Dogs & Cats- Valley Wide

EQUINE

MOBILE ACUPUNCTURE

Traditional Chinese Veterinary Medicine (TCVM) for Horses-Valley Wide

SOUL PUPPY

HOLISTIC HEALING

Downtown MESA TCVM-Acupuncture Specialty Office for Dogs & Cats

WELCOME TO BROWN VETERINARY HOUSECALLS

Local, Veterinarian Owned & Operated, Private Practice!

Colleen Brown DVM

In Person Appointments: Tues, Wed, Thurs (afternoons/early evenings)

In Home Euthanasia pre-scheduled as last appointment of day

Virtual Office Hours: Friday (TeLeVET Time)

Closed: Sat, Sun, Mon, All Holidays

EMERGENCY RESOURCES

This is not an emergency, same day, urgent response or concierge service

Thank you!

#NOTONEMOREVET

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

brownvetservices.com

Herbal Prescription Request & Refill Form

This form is for herbal prescriptions & refills for current TCVM patients being actively treated with acupuncture & herbal medicine by Dr. Brown. VCPR required by law.

PROCESSING INFO

Please submit this form for all Herbal Prescription Refill requests & Nutriherb or Mushroom orders

Please allow up to 1 to 3 business days for approval and processing via Dr. Brown (does not include Jing Tang processing or shipping time). Learn more . Payment must be received prior to shipping.

Herbal Rx Refill Request

Name (required)

First Name (required)	Last Name (required)

Shipping Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Email address (required)

Cell
Phone Type	Phone Number

MUSHROOM SUPPLEMENTS via Jing Tang

Please choose one if applicable

Immunoshroom 6 (Reishi, Turkeys Tail, Shiitake, Maitake, Chage, Cordyceps) Capsules
Immunoshroom 6 (Reishi, Turkeys Tail, Shiitake, Maitake, Chage, Cordyceps) Powder
Triobalancer 100 Organic Mushroom Blend (Lions Mane, Cordyceps, Reishi) Capsules
Triobalancer 100 Organic Mushroom Blend (Lions Mane, Cordyceps, Reishi) Powder

To request additional mushroom blends please list in box below

Please check box if you would like additional information emailed to you regarding Mushroom Supplements

NUTRIHERB SUPPLEMENTS via Jing Tang (combination of Western Neutraceuticals & Chinese Herbs)

Please choose one if applicable

Bright Mind Capsules
Bright Mind Powder
Canine Antioxidant
Heart Support
Joint Support Capsules
Joint Support Powder

To request additional Nutriherb blends please list in box below

Please check box if you would like additional information emailed to you regarding Nutriherb Supplements

JING TANG HERBAL REFILL ONE

Name of Pet-Patient

Name of Herbal refill request :

Strength of blend requested above :

Current dose being given to patient :

Please use this space to provide additional patient dosing updates or questions for Dr. Brown

JING TANG HERBAL REFILL TWO

Name of Pet-Patient

Name of Herbal refill request :

Strength of blend requested above :

JING TANG HERBAL REFILL THREE

Name of Pet-Patient

Name of herbal refill request :

Strenght of herbal requested above :

JING TANG HERBAL REFILL FOUR

Name of Pet Patient

Name of herbal refill request :

Strength of blend requested above :

JING TANG HERBAL REFILL FIVE

Name of Pet Patient

Name of herbal refill request :

Strength of herbal requested above :

JING TANG HERBAL REFILL SIX

Name of Pet Patient

Name of herbal refill request :

Strength of herbal requested above :

Please list current dosing being given to patient (s) or questions for Dr. Brown. Thank you

Preferred Payment Method (required)

Paypal invoice
Zelle
Venmo

Verify the reCAPTCHA:

Thank you for your referrals!

PROUD TO BE LOCALLY OWNED & OPERATED BY DR. BROWN

BY APPOINTMENT ONLY

Grey colored dog, cat and horse icon

Appointment Hours

Variable based on location & availability

Tues, Wed, Thurs

(afternoons/early evenings)

Business Hours

Tues-Fri 1PM-6PM

CLOSED: Sat, Sun, Mon & Holidays

Virtual Office Hours

Friday only

*subject to change without notice

Colleen Brown DVM

Integrative Veterinarian

Text scheduling for ACTIVE patients & PREAPPOVED new clients

480-648-4401

Individuals with disabilities or elderly in need of assistance please contact Dr. Brown in the manner that best allows us to serve you. See contact page for more info

LOCAL VETERINARY COLLEAGUES

For mutual patient consults please contact Dr. Brown via email at brownvethc@gmail.com, text at 480-648-4401 or phone at 480-494-6034 (press # to bypass recording and a leave message). Please email records@brownvetservices.com for all medical record requests. Thank you

Providing In Home Veterinary Care:

Phoenix, Arizona

Mesa 85205 Hub

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