Prescription Refill Request

Please use this form to request a refill of your pet's medications. Please note the following:

Refill requests should be submitted in advance. Please allow up to 3 business days for medications to be refilled, as our specialty services are not open 24/7.
Refills must be authorized by the prescribing veterinarian. Our emergency department will not authorize refills for patients under the care of our specialty departments.
We will not refill medications that we did not originally prescribe, or if we have not seen your pet in the past 6 months.
If you wish to have a medication refilled by your pet's primary care veterinarian, please contact your primary care hospital directly, as they cannot dispense medications on our behalf.
We will inform you when it is ready for pickup by telephone or email during weekdays and normal business hours.

Your Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Pet's Name*

Which service last saw your pet?*

Which medication(s) would you like refilled?*

	Medication Name	Strength	Quantity
Medication 1
Medication 2
Medication 3

Please select one:*

I would like to pick up the refill from Eastern Carolina Vet.I would like to pick up the refill from an external pharmacy. [Please note that veterinary-specific medications may not be available at local pharmacies.]

External Pharmacy Name*

External Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

External Pharmacy Phone Number*

Please enter a valid phone number.

Additional comments: