Prescription Refill Request Form

Prescription Refill Request Form

Please complete one form for each requested prescription. All requests submitted here will be filled in our hospital.
Your Name*

First NameLast Name
Phone Number*
Please enter a valid phone number that we can call or text with questions and/or to notify you that your prescription is ready.
Pet's Name*
Name & Strength of Requested Medication*
Quantity Requested*
PLEASE NOTE THAT SOME CONTROLLED SUBSTANCE PRESCRIPTIONS MAY NOT EXCEED A 30 DAY SUPPLY.
Due to weather-related supply chain interruptions, some supplies may be limited and we may not be able to grant your requested quantity. We will do our best to fill every request and appreciate your understanding around the limitations outside of our control.
If approved, would you be interested in a 90-day supply of this medication? Please note, it may take 1-2 business days depending on available stock and there may be restrictions for some controlled substances.*

YesNo
Current Dose & How Pet is Responding*
Please add a note as to how you're giving your pet's medication and how they are doing with it.
Note to Medical Staff:
By checking the box below, you understand that prescriptions may take 24-48 hours to be reviewed by your regular veterinarian depending on their schedule and hospital hours. Prescription refill requests may NOT be processed during Saturday or Sunday hours. Please allow additional time for controlled substances.*

I understand the above statement
Please click the box below if you need this prescription filled today. Same-day refill requests may incur a Same Day Refill Request fee ($9.00), some prescriptions may not be available based on hospital stock, and the quantity you request may not be approved if your regular veterinarian is not available to review the request. Same day refill requests may NOT be processed during Saturday and Sunday hours.

I would like to pick up my prescription today and understand it may incur a $9.00 Same Day Refill Request fee. I also understand that this may not be possible during Saturday and Sunday hours.I changed my mind and I can't unclick the box above (thanks for the feedback ; )
Should be Empty:

Prescription Refill Request Form

Due to weather-related supply chain interruptions, some supplies may be limited and we may not be able to grant your requested quantity. We will do our best to fill every request and appreciate your understanding around the limitations outside of our control.