Refill request form (Piroxicam, Chlorambucil only)

Please Note: This form is to be used for patients who are on an active oral chemotherapy or metronomic treatment plan and need refills of either piroxicam or chlorambucil.

**Appropriate labwork should be included with the refill request*

Please visit www.veterinaryoncologypartners.com for more information.

Date

Today's Date

Which drug(s) are you wanting to order more of today? (MAY CHECK MORE THAN ONE)*

ChlorambucilPiroxicam

Client Name*

First NameLast Name

Patient Name*

Age (in years)*

# only, Ex: "1.5" or "0.5"

Sex*

Breed*

Species*

CanineFelineOther

Weight (in pounds)*

Pounds, NOT Kg

Veterinarian Name*

First NameLast Name

Veterinarian Email *

example@example.com

Veterinarian Phone Number (cell phone or office number)*

Veterinarian Fax Number*

Please enter a valid phone number. If you do not have Fax, then just enter 0s

Hospital / Practice Name*

Veterinary Hospital / Practice Address (Must be the practice address. We CANNOT ship chemotherapy directly to a pet owner)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Diagnosis*

You have selected "Other", please explain:

Has this patient had recent labwork?*

YesNo

Labwork monitoring is strongly recommended while on Piroxicam and/or Chlorambucil. In the case of Piroxicam, we always watch for signs of GI bleeding and renal toxicity. With chlorambucil you must watch for bone marrow suppression which can happen over time. Patients can be fine for many months on these medications before side effects show up so diligent monitoring is recommended.

Piroxicam: CBC and chem/lytes recommended every 2 months long-term.

Chlorambucil: CBC at 2 weeks, then a 1 month, then every 2 months long-term.

By checking the box below you acknowledge that labwork was recommended but is not an option at this time (financial, logistics, etc) and the owner has been educated as to potential side effects and risks of refilling these medications without proper monitoring.*

Please refill medications as requested below.

Date of most recent lab work*

Date

Please upload most recent labwork (CBC +/- Chemistry). *

Is this patient on steroids of any kind?*

YesNo

Date of Last steroid given:

Authorizing Veterinarian Name*

How many day supply would you like to order for this patient?*

30 day supply60 day supply90 day supply

30 Day Supply Pricing: By clicking the box below, I (listed above) authorize Veterinary Oncology Partners to charge my credit card on file and script chemotherapy to be sent to my hospital for the following chemotherapy protocol as previously recommended: (CHOOSE ALL THAT APPLY)*

60 Day Supply Pricing: By clicking the box below, I (listed above) authorize Veterinary Oncology Partners to charge my credit card on file and script chemotherapy to be sent to my hospital for the following chemotherapy protocol as previously recommended: (CHOOSE ALL THAT APPLY)*

90 Day Supply Pricing: By clicking the box below, I (listed above) authorize Veterinary Oncology Partners to charge my credit card on file and script chemotherapy to be sent to my hospital for the following chemotherapy protocol as previously recommended: (CHOOSE ALL THAT APPLY)*

Please let us know if you have any specific concerns or questions!*