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
Co-Owner Name

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

Text MessageEmailPhone CallAny
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?)*
Your Employer AND/OR Occupation
Co-Owner's Employer And/or Occupation
How did you hear about us
Name of Pet*
Type of Pet*

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*
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?*

NoYesOther
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
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 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, I 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. I understand that 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. Communications will be returned during regular business hours only. Text and emails are preferred as a record of communications. A consult fee of $30 for a text consult or $55 for a phone call may be applied for new medical issues as a telemedicine visit, unless you are a concierge client.

7. To provide the most optimal care, certain preventative medicine is required to maintain your pet as a patient:

- Annual bloodwork once considered a senior pet, increased to every 6 months for chronic medications.

- Current of vaccinations or titers as discussed.

8. I understand if my pet is aggressive or territorial, Dr. Braun has the right to refer me to another practice.

9. I agree to the 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 documentation fee will be applied to my account.

10. 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.

Thank you for trusting Braun Veterinary Housecalls for your pet's healthcare needs!
I agree to these practice policies.

Clear
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*

Clear
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*

Clear
Date of Signature*

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

Cash, Zelle and checks are preferred.

Credit cards may incur a transaction fee of 2%.
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Braun Veterinary Housecalls Medical/Wellness Consult Registration Form