Prescription Refill Request
Please allow up to 3 days to complete refill requests
OWNER Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone (best number to reach you at)
*
Please enter a valid phone number.
Patient Information
Kitty's Name
*
Medication
For each medication, fill in the name of the drug, the dosage and the quantity needed and click the add button.
How do you want to submit your prescription request?
*
Upload Photo(s) of Medication Label(s)
Add Each Medication Separately (up to 4)
Upload a Picture(s) of the Medication Label(s) You Want to Refill
*
Browse Files
Drag and drop files here
Choose a file
Max total file upload is 20MB
Cancel
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Additional Information
Please include any additional information that you feel may help us in filling the medication request(s) for your cat.
SECTION: 1st Prescription
Drug Name
*
What is the name of the medication?
Dose
*
How much (.02 ml) is given?
Frequency
*
How often (every 8-12 hours) is it given?
Strength
*
Example: 10mg per tab, 10mg per ml, etc
Quantity Needed
*
How many days of medication do you need?
Additional Information
Please include any additional information that you feel may help us in filling the medication request for your cat.
Add Another
Add Another Prescription
SECTION: 2nd Prescription
Second Drug Name
*
What is the name of the medication?
Dose
*
How much (.02 ml) is given?
Frequency
*
How often (every 8-12 hours) is it given?
Strength
*
Example: 10mg per tab, 10mg per ml, etc
Quantity Needed
*
How many days of medication do you need?
Additional Information
Please include any additional information that you feel may help us in filling the medication request for your cat.
Add Another
Add Another Prescription
SECTION: 3rd Prescription
Third Drug Name
*
What is the name of the medication?
Dose
*
How much (.02 ml) is given?
Frequency
*
How often (every 8-12 hours) is it given?
Strength
*
Example: 10mg per tab, 10mg per ml, etc
Quantity Needed
*
How many days of medication do you need?
Additional Information
Please include any additional information that you feel may help us in filling the medication request for your cat.
Add Another
Add Another Prescription
SECTION: 4th Prescription
Fourth Drug Name
*
What is the name of the medication?
Dose
*
How much (.02 ml) is given?
Frequency
*
How often (every 8-12 hours) is it given?
Strength
*
Example: 10mg per tab, 10mg per ml, etc
Quantity Needed
*
How many days of medication do you need?
Additional Information
Please include any additional information that you feel may help us in filling the medication request for your cat.
End Section
Pickup Information
Date Desired
*
-
Month
-
Day
Year
Please allow 3 business days to fill this request.
Time Desired:
*
Please select...
Early Morning (8 a.m.–10 a.m.)
Mid-Morning(10 a.m.–12 p.m.)
Mid-Day (12 p.m.–2 p.m.)
Mid-Afternoon (2 p.m.–4 p.m.)
What time of day do you plan to stop by? Morning pickup only on Thursdays and Saturdays.
Please verify that you are human
*
Submit
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