DROP OFF • SURGICAL CONSENT • DENTAL FORM • PRESCRIPTION REFILL

ONLINE PRESCRIPTION REFILL REQUEST

If you are currently a client and we have prescribed a medication (including heartworm and flea meds, as well as prescription food) for one of your pets, you can submit this form to request a refill of that prescription. We will then contact you within 1 business day to let you know if, and when, it’s ready. If you are requesting refills for more than 1 pet, you will need to submit a form for each pet. Please note that refills for controlled drugs must be requested 4 business days prior to when we need to have them ready for you.

Client and Patient Information:
Your Name:		Your Pet's Name:
Phone:		Alternate Phone:
Email Address:

Do you prefer that we contact you regarding this prescription by: Phone Email

Do you prefer to pick the medication up or have it mailed* to you: Pick Up Mail * mailing via the USPS will incur an additional charge determined by product size & weight

Requested Prescription(s):
Medication Description #1
Name of Medication		Form of Medication
Dosage Size/Strength		Quantity Desired

Medication Description #2
Name of Medication		Form of Medication
Dosage Size/Strength		Quantity Desired

Medication Description #3
Name of Medication		Form of Medication
Dosage Size/Strength		Quantity Desired

Medication Description #4
Name of Medication		Form of Medication
Dosage Size/Strength		Quantity Desired

Current Medications:
Please list the names & dosages of all drugs or nutritional supplements your pet currently takes & day of last dose.
Current Medication Description #1
Name of Medication
Dosage Taken		Date of Last Dose

Current Medication Description #2
Name of Medication
Dosage Taken		Date of Last Dose

Current Medication Description #3
Name of Medication
Dosage Taken		Date of Last Dose

Current Medication Description #4
Name of Medication
Dosage Taken		Date of Last Dose

Progress Report:
Has your pet had any of the following within the past week?
Behavioral changes?	Yes No
	Please Describe:


Changes in appetite?	Yes No
	Please Describe:


Diarrhea or vomiting?	Yes No
	Please Describe:


Any other concerns?	Yes No
	Please Describe: