Registration Form - Braun Veterinary Housecalls

Braun Veterinary Housecalls Medical/Wellness Consult Registration Form

WE KNOW YOUR PET’S HEATH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP USPROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!
Name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Co-owner's Name

First NameLast Name
Co-owner's phone Number
Please enter a valid phone number.
Email*
example@example.com
Co-Owner Email
example@example.com
Preferred Method of Contact*

Text MessageEmailPhone CallAny
Do you consent to recieve text messages from Braun Veterinary Housecalls

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address IF DIFFERENT

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any parking restrictions/recommendations, Or gate codes or other pertinent info for us finding your home? *
Any arrival requests (i.e., should we text or call when we arrive or knock or ring doorbell?)*
For any lab results, what is your preferred method of receiving them? Email, text, phone call, or other? *
Your Employer AND/OR Occupation
Co-Owner's Employer And/or Occupation
How did you hear about us
Pet's Name*
Species*

DogCatSmall mammalReptileOther
Sex*

Neutered MaleIntact MaleSpayed FemaleIntact Female
Breed*
Color*
Birth Date/Age*
Previous Clinic
Reason for Visit*
Please describe any medical concerns - when first noticed, any changes, any treatments attempted
Current Diet and Treats - Brands and Amount*
Current Medications AND Supplements*
Current Heartworm and/or Flea Preventatives and DATE when Last Administered*
Is you pet current on rabies vaccination OR rabies titer testing?*

NoYesUnsureNo, but I'm interested in updating it
Is you pet current on other vaccinations or titers?*

NoYesUnsureNo, but I'm interested in updating itI prefer vaccine titiersOther
Has your pet had a full blood panel in the last 12 months?*

NoYesUnsureOther
Is your pet indoors or outdoors or both? If both, please elaborate (does your pet catch animals, does your pet stay in the yard or wander, do you visit parks or other homes with your pet, etc.?)
Any Change in Thirst Levels or Urination Habits?*

YesNoUnsure
If yes, please elaborate
Any Vomiting or Diarrhea?*

YesNoUnsure
If yes, please elaborate
Any Known Allergies?*

None knownYesUnsure
If yes, please elaborate
Any History of Biting or Other Aggressive Behaviors*

None knownYes
If yes, please elaborate
How does your pet normally act when visitors come to your house? *
How does your pet normally act at the veterinarian?*
Does your pet resent being touched anywhere or dislike restraint? If yes, please elaborate*
If you chose complimentary above, what modalities would you be interested in

AcupunctureTCVM (chinese herbs)Western HerbsHomeopathy
Any History of Vaccination Reactions?*

None knownYes
Do you have Pet Insurance?*

NoYes
Do you give permission for photos/videos of your pet and their health story to be used for social media posts? This may include pet's name but will not include any owner information.*

NoYesOther
We offer an integrative approach, a mix of conventional and complimentary medicine. Are you interested in:

A strictly conventional approachPrimarily conventional with a bit of complimentaryPrimarily complimentary with a bit of conventionalVaries/other
Do you give permission for photos/videos of your pet and their health story to be used for speaking engagements, website design or promotional materials for Dr Jana Braun?*

NoYes
AUTHORIZATION
I hereby authorize Dr Braun to perform an exam and other diagnostics and treatments as decided on on my pet.

Per WA Law WAC 246-933-345 You need to be aware of any potential outcomes from any treatment:

Vaccination Reactions are uncommon but may occur. Common reactions are mild post-vaccination lethargy or malaise, mild swelling, itching or pain at the injection side. Rare reactions include anaphylactic shock – including facial swelling, hives, vomiting and diarrhea, Extremely rare include shock/collapse and death, or immune-mediated disease. The benefits of these vaccinations do outweigh the rare risk.

Venipuncture (blood draw) are low risk but may cause bruising or swelling. In rare cases of clotting disorders, additional bleeding may be seen.

All efforts will be made to provide medical information sheets for medications.

I certify that I have not been made any medical promise of success or guarantee of outcome of service. I understand that every medical condition is different and outcomes are based upon multiple factors.

This authorization serves for today and further treatments unless revoked in writing.
Signature*

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COVID STATEMENT
I understand the risks presented by potential necessary close contact with Dr. Jana Braun. I will not hold Dr. Braun or Braun Veterinary Services, PLLC responsible for any potential exposure.

If I or anyone in my household develops ANY potential symptoms of COVID-19 or any infectious disease, I will immediately inform Dr. Braun. No cancellation fees apply for cancelling due to illness.
Signature*

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Date of Signature*

MonthDayYear
Date
Cash, check, Zelle, Venmo and credit cards are accepted.

Cash, Zelle and checks are preferred.

Venmo will incur a transaction fee of 1.5%

Credit cards may incur a transaction fee of 2.5-3.3%.
Practice Policies

1.       When scheduling an appointment or during your first appointment, a copy of your pet's previous medical history will be needed. Please request these be sent to info@braun.vet. We can request them ourselves if needed but you requesting them yourself will expedite the appointment-making process.

2.       If you need to cancel an appointment, please provide at least 24 hours advance notice. Failure to do so may result in a cancelation fee of $50. If Dr. Braun shows up for an appointment and you are not home or the pet is not available, full cost of housecall and exam will be charged.

3.       By scheduling an appointment, you agree to pay for all services performed during the visit. An estimate can be provided prior to all services upon request.

4.       Payment is due at the time services are rendered. At this time, cash, checks, Zelle, Venmo and credit cards (Visa, Mastercard, Discover & American Express) are accepted. A processing fee may be applied to credit card purchases.

There is a $25 fee for returned checks, and a $15 per month statement and accounting fee charged on the 1st of each month after the visit for all accounts with outstanding balances.

In the event of a collection, all reasonable collection fees, attorney fees and court costs will be paid by the client. (Please note that Care Credit is NOT accepted).

5.       Braun Veterinary Services, PLLC, d.b.a. Braun Veterinary Housecalls does not have the capabilities to perform x-rays, dentistry or surgery, and is not available for 24-hour emergency services. You are welcome to work with any veterinarian with whom you have a prior relationship, or one can be recommended. The veterinarian you see may make recommendations based on their testing, but if your pet is referred for one of these services the results will also be reviewed by Dr. Jana Braun and a plan will be discussed for your pet's ongoing health care needs.

6.       Dr. Braun and staff do not have a mobile clinic. Exams, blood draws and any treatments will be performed in the home or other areas as agreed upon.

7.       Telemedicine visits are available and are great for small issues that arise or rechecks $70 per 15 minutes of Zoom/phone discussion OR $50 for a text consultation, as long as your pet has had a wellness exam in the last 12 months. Additionally fees may be charged for after hours or weekend visits. It is Dr. Braun’s discretion whether a fee will be charged but in general, ror quick questions, there is no charge. For anything that requires documentation in a patient’s chart, a fee of up to above amounts may be charged.

8.       Communications will be returned ONLY during regular business hours. Text and emails are preferred as a record of communications for documentation purposes.

9.       Certain minimum standards of care are required to remain an active patient of Braun Veterinary Housecalls.

-          Adult pets are required to have an annual wellness exam.

-          Senior pets are required to have twice annual wellness exam.

-          Bloodwork done annually when he/she reaches 9 years of age, earlier for large dogs.

-      Bloodwork every 6 months may be necessary for certain medications.

-      Pets must remain current on recommended vaccinations or titers.

10.   We do not see aggressive pets. If your pet is aggressive or territorial, Dr. Braun has the right to refer to another practice. Some pets are more protective of their home environments.

11.   Prescription policy - prescriptions will be available through Dr. Braun's pharmacy or a written prescription will be given. If telephone approval is necessary/requested, a $7 telemedicine fee will be applied to your account. Medications that Dr. Braun does not carry are exempt from this fee.

12.   Braun Veterinary Housecalls will not tolerate rude, derogatory, belligerent, threatening or otherwise discourteous behavior. We expect all clients and family members to be respectful and courteous at all times.
I have reviewed all pricing information.

* If you would like a specific estimate of services, please contact us ASAP.
I agree to these practice policies.

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Braun Veterinary Housecalls Medical/Wellness Consult Registration Form