Medication Refill Request

MEDICATION REFILL FORM

Please enter all the required information for submission. We will be in contact with you soon regarding your request. Thank you.
Name of Primary Pet Parent on the Account*

First NameLast Name
Pet's Name*
Confirm Your Email Address*
example@example.com
We will contact you via email regarding the status of your refill request within 1 to 2 business days.
Choose how you want to obtain your pet's medications.

Pick Up At The ClinicHave it Shipped To My HouseHave it Called into a Local Human PharmacyPick Up and Have Shipped since IPLEX and other oral supplements are only available for shipment when refilling.
IMPORTANT

We require payment to reserve medications for pick up.

Once paid, PLEASE WAIT for the "Ready for Pick up!" email before coming to the clinic.

OUR BUSINESS HOURS HAVE CHANGED!

Monday, Wednesday, Thursday and Friday: 9 am to 4 pm

Closed on Tuesdays and Weekends.

(subject to change without notice)
IMPORTANT

We require payment to reserve medications for pick up and to order medications for drop shipment.

Once paid, PLEASE WAIT for the "Ready for Pick up!" email before coming to the clinic.

OUR BUSINESS HOURS HAVE CHANGED!

Monday, Wednesday, Thursday and Friday: 9 am to 4 pm

Closed on Tuesdays and Weekends.

(subject to change without notice)

Some medications or topical supplements cannot be shipped from the clinic, however, they are purchaseable online without a prescription:
- Optixcare Gel 'PLUS'
- Optixcare Eye Health
- I-Drop Vet Gel or Plus
- Vizoovet Protect Drops (https://petnetwork.shop) *Two options: 10 ml bottle or box of 10 ampules!
- Can-C Cataract Eye Drops (https://www.wisechoicemedicine.com/product/can-c-is-for-dogs-too/)
IMPORTANT

We require payment to order medications for drop shipment.

Some medications or topical supplements cannot be shipped from the clinic, however, they are purchaseable online without a prescription:
- Optixcare Gel 'PLUS'
- Optixcare Eye Health
- I-Drop Vet Gel or Plus
- Vizoovet Protect Drops (https://petnetwork.shop) *Two options: 10 ml bottle or box of 10 ampules!
- Can-C Cataract Eye Drops (https://www.wisechoicemedicine.com/product/can-c-is-for-dogs-too/)
What is the Name of the Pharmacy?
Pharmacy Phone Number
IMPORTANT INFORMATION REGARDING HUMAN PHARMACIES:

Most human pharmacies rely on medical insurance or similar to cover majority of the cost of medications. That said, when requesting to have one of the medications listed below called in for your pet, you cannot use your health insurance to cover the cost as the prescription will be under {petsName}, not you.

If the pharmacy price of a medication seems unreasonable to you, feel free to compare cost by coming back here and selecting for Pick Up or Shipment. Once you choose your pet's medication, the prices populate expedite your order.
Please confirm the address you would like for shipping:

Street Address

Street Address Line 2 (ex. Apt E, Unit 101, Suite 3400, etc.)

CityState

Zip Code

Which medication(s) are you looking to have called in? Only the medications shown can be called into a human pharmacy.
Diclofenac Ophthalmic Drops, 5 ml bottle
Dorzolamide Ophthalmic Drops, 10 ml bottle
Dorzolamide with Timolol Ophthalmic Drops, 10 ml bottle
Ketorolac Ophthalmic Drops, 10 ml bottle
*Please note, most pharmacies only carry the 5 ml bottles.
Latanoprost Ophthalmic Drops, 2.5 ml bottle
NeoPolyBacitracin Ophthalmic Ointment, 3.5 gm tube
NeoPolyDexamethasone Ophthalmic Ointment, 3.5 gm tube
NeoPolyDexamethasone Ophthalmic Drops, 5 ml bottle
NeoPolyGramicidin Ophthalmic Drops, 10 ml bottle
Ofloxacin Ophthalmic Drops, 5 ml bottle
Pred Acetate Ophthalmic Suspension, 5 ml bottle
Tobramycin Ophthalmic Drops, 5 ml bottle
I am looking for a refill of oral Pilocarpine from Enovex Pharmacy.
Over-the-counter (OTC) Eye Medications and Other Recommendations Without Prescription:
- Sodium Chloride Drops and Ointments (brand name is Muro 128)
- Artificial Tears Ointment (ex. GenTeal Nigh-Time Ointment)
- Artificial Tears Gel Drops (ex. GenTeal Severe Gel Drops, Refresh Celluvisc Eye Gel, etc.)
- Saline Eye Rinse
- Ketotifen Drops (brand names are Zaditor and Allaway)
Eye Drop Recommendations Purchaseable Online Without Prescription:
- Optixcare Gel 'PLUS'
- Optixcare Eye Health
- I-Drop Vet Gel or Plus
- Vizoovet Protect Drops (https://petnetwork.shop) *Two options: 10 ml bottle or box of 10 ampules!
- Can-C Cataract Eye Drops (https://www.wisechoicemedicine.com/product/can-c-is-for-dogs-too/)

Available for Pick Up AT THE CLINIC
Bo Yun San Ophthalmic Powder
Canine Immune Support powder, 30 gm bottle
Canine Immune Support powder, 110 gm bottle
Can-C Eye Drops (tiered pricing)
*Expires 30 days after opening.*
Cyclosporine 1% Ophthalmic Drops, 10 ml bottle
Cyclosporine 2% Ophthalmic Drops, 10 ml bottle
Cyclosporine/Tacrolimus 2%/0.03% Ophthalmic Drops, 10 ml bottle
Cyruta tablets, 90 count bottle
Demecarium Bromide 0.125% Ophthalmic Drops, 10 ml bottle
Demecarium Bromide 0.25% Ophthalmic Drops, 10 ml bottle
Diclofenac Ophthalmic Drops, 5 ml bottle
Dorzolamide Ophthalmic Drops, 10 ml bottle
Dorzolamide with Timolol Ophthalmic Drops, 10 ml bottle
EDTA 2% Ophthalmic Drops, 10 ml bottle
Feline Immune Support tablets, 90 count bottle
Immune Mushroom Formula, 4 oz can
Immune Mushroom Formula, 8 oz bag
Ketorolac Ophthalmic Drops, 10 ml bottle
Ketotifen Ophthalmic Drops, 10 ml bottle
*Only available for pick up.*
Latanoprost Ophthalmic Drops, 2.5 ml bottle
NeoPolyBacitracin Ophthalmic Ointment, 3.5 gm tube
NeoPolyDexamethasone Ophthalmic Drops, 5 ml bottle
NeoPolyDexamethasone Ophthalmic Ointment, 3.5 gm tube
NeoPolyGramicidin Ophthalmic Drops, 10 ml bottle
Neurotrophin PMG tablets, 90 count bottle
Oculotrophin PMG tablets, 90 count bottle
Ofloxacin Ophthalmic Drops, 5 ml bottle
OPC Synergy capsules, 40 count bottle
Ophthalmic Lubricating Ointment (Artificial Tears)
Ophthalmic Lubricating Drops (Artificial Tears), 15 ml bottle
Optimmune Ophthalmic Ointment, 3.5 gm tube
Optixcare Gel 'PLUS', 20 gm tube
Pred Acetate Ophthalmic Suspension, 5 ml bottle
Saline Eye Rinse
*Only available for pick up.*
Sodium Chloride Ophthalmic Ointment, 3.5 gm tube
*Only available for pick up.*
Sodium Chloride Ophthalmic Drops, 15 ml bottle
Tacrolimus 0.03% Ophthalmic Drops, 15 ml bottle
Terramycin Ophthalmic Ointment, 3.5 gm tube
Tobramycin Ophthalmic Drops, 5 ml bottle
Vizoovet Protect Ophthalmic Drops, 10 ml bottle
*Expires 90 days after opening.*
Projected Total for Pick Up

Available for AUTO-SHIPMENT through our Chewy.com Partnership
PLEASE NOTE: Anything selected for Chewy Autoship, will require a Chewy.com account. Please provide us with the email you use or will use for your account so that we can submit the prescription and you can process your order through Chewy with ease.
Is the email entered above the best email for your Chewy.com account? If not, enter the preferred email where prompted below:

Yes, use the email address above.
Dexamethasone Ophthalmic Drops, 5 ml bottle
*Drop Shipped Item.*
Dorzolamide Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Dorzolamide with Timolol Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Ketorolac Ophthalmic Drops, 5 ml bottle
*Drop Shipped Item.*
Ketorolac Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Latanoprost Ophthalmic Drops, 2.5 ml bottle
*Drop Shipped Cooler Item.*
NeoPolyDexamethasone Ophthalmic Ointment, 3.5 gm tube
*Drop Shipped Item.*
Optimmune Ophthalmic Ointment, 3.5 gm tube
*Drop Shipped Item.*
Sodium Chloride Ophthalmic Ointment, 3.5 gm tube
*Drop Shipped Item.*

Available for SHIPMENT (typically arrives in 2 to 5 business days)
Blood Heat Formula Concentrated 0.2 gm capsules, 50 count bottle
*Drop Shipped Item.*
Blood Heat Formula Concentrated 0.5 gm capsules, 100 count bottle
*Drop Shipped Item.*
Bo Yun San Ophthalmic Powder
*Drop Shipped Item.*
Canine Immune Support powder, 30 gm bottle
*Drop Shipped Item.*
Canine Immune Support powder, 110 gm bottle
*Drop Shipped Item.*
Cyclosporine 1% Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Cyclosporine 2% Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Cyclosporine/Tacrolimus 2%/0.03% Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Cyruta tablets, 90 count bottle
*Drop Shipped Item.*
Diclofenac Ophthalmic Drops, 5 ml bottle
*Drop Shipped Item.*
Demecarium Bromide 0.125% Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Demecarium Bromide 0.25% Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
EDTA 2% Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Concentrated Facial P Formula 0.5 gm capsules, 100 count bottle
*Drop Shipped Item.*
Famciclovir 125 tablets, 30 count bottle
*Only Available for Drop Shipment.*
Famciclovir 250 mg tablets, 30 count bottle
*Only Available for Drop Shipment.*
Feline Immune Support tablets, 90 count bottle
*Drop Shipped Item.*
Concentrated Haliotis 0.2 gm capsules, 50 count bottle
*Drop Shipped Item.*
Concentrated Haliotis 0.5 gm capsules, 100 count bottle
*Drop Shipped Item.*
I-Drop Vet Plus Ophthalmic Drops, 10 ml bottle
*Only available for drop-shipment.*
EYE-Plex (formerly known as IPLEX) capsules, 150 count bottle
*Only Available for Drop Shipment.*
Ketorolac Ophthalmic Drops, 5 ml bottle
*Drop Shipped Item.*
Latanoprost Ophthalmic Drops, 2.5 ml bottle
*Drop Shipped Cooler Item.*
Concentrated Long Dan Xie Gan 0.5 gm capsules, 100 count bottle
*Drop Shipped Item.*
Concentrated Max's Formula 0.18 gm teapills, 200 count bottle
*Drop Shipped Item.*
Concentrated Max's Formula 0.2 gm capsules, 50 count bottle
*Drop Shipped Item.*
Concentrated Max's Formula 0.5 gm capsules, 100 count bottle
*Drop Shipped Item.*
NeoPolyBacitracin Ophthalmic Ointment, 3.5 gm tube
*Drop Shipped Item.*
NeoPolyDexamethasone Ophthalmic Drops, 5 ml bottle
*Drop Shipped Item.*
NeoPolyGramicidin Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Neurotrophin PMG tablets, 90 count bottle
*Drop Shipped Item.*
Oculotrophin PMG tablets, 90 count bottle
*Drop Shipped Item.*
Ofloxacin Ophthalmic Drops, 5 ml bottle
*Drop Shipped Item.*
OPC Synergy capsules, 40 count bottle
*Drop Shipped Item.*
Optimmune Ophthalmic Ointment, 3.5 gm tube
*Drop Shipped Item.*
Optixcare Gel 'PLUS', 20 gm tube
*Drop Shipped Item.*
Pred Acetate Ophthalmic Suspension, 5 ml bottle
*Drop Shipped Item.*
Pilocarpine 0.1% Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Pilocarpine 1% Ophthalmic Drops, 10 ml bottle
*Drop Shipped Item.*
Sodium Chloride Ophthalmic Drops, 15 ml bottle
*Drop Shipped Item.*
Tacrolimus 0.03% Ophthalmic Drops, 15 ml bottle
*Drop Shipped Item.*
Terramycin Ophthalmic Ointment, 3.5 gm tube
*Drop Shipped Item.*
Tobramycin Ophthalmic Drops, 5 ml bottle
*Drop Shipped Item.*
Concentrated Wu Ling San 0.5 gm capsules, 100 count bottle
*Drop Shipped Item.*
Projected Total for Shipment

end of all previous up above
If you have not seen the medication you are seeking a refill for, please write the name of the medication(s) in the box below:
NOTE: If this medication adds an additional cost, we will adjust the grand total and invoice as you indicate below.

Last Step: Processing Payment
IMPORTANT:

Once your payment has been processed, we will email you when your order is ready for pick up. From that point, you will have up to five business days to pick up your medication before it will be restocked.

If your medication(s) needs to restocked, you will be refunded the total amount less a 10% restocking fee.

We will do our best to provide a courtesy reminder before medications are restocked,however, please be sure to check your junk or spam emails if you have seen your payment processed but have not received an email from us within a day of your payment.
IMPORTANT:

Should your request be approved, we will email you when we have called in the requested medication.

We will include the prescription details and the name of who we spoke to or if we had to leave a voicemail.

From that point, you will then be able to reach out directly to the pharmacy to fulfill your refill.
IMPORTANT FOR CHEWY.COM PRESCRIPTION ORDERS:

If your request is approved, Chewy will email you and/or send a notification to your Chewy app once they have received our direct prescription.

We will also email you to let you know that your request has been completed as confirmation.

Please keep in mind that you will need to go to the app or website to compelte your order and process your payment through Chewy.
PROJECTED GRAND TOTAL FOR YOUR ORDER:
How would you like to process payment for your refill request?

Charge any card that I have on file.I'll pay now with my Debit or Credit card to expedite things.I'll pay now with my CareCredit card to expedite things.
I understand that pre-paying is optional and only meant to expedite my refill and does not guarantee approval of this request.

Acknowledged.
I understand that pre-paying is optional and only meant to expedite my refill and does not guarantee approval of this request.

Acknowledged.
Direct Payment to IOP via CareCredit:

To facilitate payment via CareCredit, we have included a link below to pay from the convenience of your smartphone, tablet or computer.

Should your request be approved, we will receive an itemized receipt via email upon payment.

*All payments over $200 are eligible for 6 months deferred interest benefits. Anything less than $200 is subject to standard interest rates*

Please take note of the amount due and click the following link to be redirected to CareCredit's website to process your payment.

IOP CARECREDIT PAYMENT PORTAL

Should be Empty:

Credit Card Information
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

MEDICATION REFILL FORM

Last Step: Processing Payment