Prescription Refill Request Form

Prescription Refill Request Form
Please review and fill out the form below.
- If you are requesting a refill / refills for multiple pets, please only submit one form per pet.
- Refills will be processed during your pet's doctor's regular business hours.
  - Dr. Joshua Elliott: Tuesday – Friday 8:00am – 6:00pm
  - Dr. Staci Goussev: Wednesday – Friday 8:00am – 8:00pm
  - Dr. Debra Klaser: Monday – Wednesday 8:00am – 6:00pm
  - Dr. Taryn Pestalozzi: Tuesday – Friday 8:00am – 6:00pm
  - Dr. Jani Remsburg: Monday – Thursday 8:00am – 5:00pm
  - Dr. Lillian Su: Monday – Thursday 8:00am – 6:00pm
  - Dr. Regina Tobin: Monday, Tuesday, Thursday 8:00am – 6:00pm
  - Emergency Doctors Friday 7:00am – Tuesday 5:00pm
    
    Dr. Rebecca Bozarth
    
    Dr. Megan Nyboer
    
    Dr. Josh Sarrazin
- We recommend refill requests are made at least a week in advance. We require all refill requests to be made at least 72 hours (3 days) in advance.
Client and Pet Information
Owner's Name:*

First NameLast Name
Pet's Name:*
Prescription Information
Name of Medication:*
i.e. deracoxib
Strength/Concentration:*
i.e. 2 mg
How much do you give per day?*
How often do you give per day?*
How many days of medication are remaining?*
Days supply requested:*
Where would you like this filled? (Please include facility name and address)*
i.e. CVS Pharmacy, 123 Meow Blvd, Cats City, OR 45678
Payment
I will pay with...*

Card on fileNew card (I agree to be texted and/or called by Sunstone to process my payment)I will pay when I pick up
Contact Information
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Prescription Refill Request Form

Client and Pet Information

Prescription Information

Payment

Contact Information