Bolton Vet - RX Refill Form

1

For medication pickup at the hospital, please fill out this form

Medications will be ready for pickup within 48 hours. For urgent refills within 24 hours, please call the hospital at (860) 646-6134.

You will receive a text message or phone call when your medication is ready to be picked up.

For delivery through our online pharmacy please click here.

2

Name* This field is required.

First Name

Last Name

3

Pet's Name* This field is required.

4

Primary Phone* This field is required.

5

Email* This field is required.

example@example.com

6

Medication Name* This field is required.

7

Medication Strength

8

How much are you giving? And how often?

9

What quantity you would like to refill?* This field is required.

10

Where is this medication normally filled?* This field is required.

At the hospital

Outside Pharmacy

11

Pick up will be at Bolton Veterinary Hospital (222 Boston Turnpike, Bolton, CT 06043).

Please allow up to 48 hours for your medication to be filled.

12

Name and Location of Outside Pharmacy

13

Do you need another medication filled?* This field is required.

Yes

No

14

#2 Medication* This field is required.

15

Medication Strength

16

How much are you giving? And how often?

17

What quantity you would like to refill?* This field is required.

18

Where is this medication normally filled?* This field is required.

At the hospital

Outside Pharmacy

19

Pick up will be at Bolton Veterinary Hospital (222 Boston Turnpike, Bolton, CT 06043).

Please allow up to 48 hours for your medication to be filled.

20

Name and Location of Outside Pharmacy

21

Do you need another medication filled?* This field is required.

Yes

No

22

#3 Medication* This field is required.

23

Medication Strength

24

How much are you giving? And how often?

25

What quantity you would like to refill?* This field is required.

26

Where is this medication normally filled?* This field is required.

At the hospital

Outside Pharmacy

27

Pick up will be at Bolton Veterinary Hospital (222 Boston Turnpike, Bolton, CT 06043).

Please allow up to 48 hours for your medication to be filled.

28

Name and Location of Outside Pharmacy

29

Do you need another medication filled?* This field is required.

Yes

No

30

#4 Medication* This field is required.

31

Medication #4 Strength

32

How much are you giving? And how often?

33

What quantity you would like to refill?* This field is required.

34

Where is this medication normally filled?* This field is required.

At the hospital

Outside Pharmacy

35

Pick up will be at Bolton Veterinary Hospital (222 Boston Turnpike, Bolton, CT 06043).

Please allow up to 48 hours for your medication to be filled.

36

Name and Location of Outside Pharmacy

37

To request additional medications, please complete a new prescription request after submitting this request.

38

Additional comments for Bolton Veterinary pharmacy technician