Prescription Request Form
We require 24-48 hours of normal days of business to fill prescriptions. If a prescription needs to be filled in less than 24 hours, a STAT service fee will be applied. Submitting this form does not guarantee the medication will be filled.
Full Name
*
First Name
Last Name
E-mail
Phone Number
*
-
Area Code
Phone Number
Pet's Name
*
Name of Medication
*
Strength of Medication
*
i.e. 300mg, 30mg/ml
How are you giving the medication
*
i.e. Giving one capsule by mouth twice daily
What Quantity are you requesting?
*
Is this prescription to be picked up at a local pharmacy?
*
Yes
NO
If so, What is the name of the pharmacy?
Pharmacy phone number
-
Area Code
Phone Number
Pharmacy FAX number or email(required to process)
Pet's Name Prescription #2
Name of Medication Prescription #2
Strength of Medication Prescription #2
i.e. 300mg, 30mg/ml
How are you giving the medication Prescription #2
i.e. Giving one capsule by mouth twice daily
What Quantity are you requesting? Prescription #2
Is this prescription to be picked up at a local pharmacy?
Yes
NO
If so, What is the name of the pharmacy?
Pharmacy phone number
-
Area Code
Phone Number
Pharmacy FAX number or email(required to process)
Submit
Should be Empty: