Prescription Medication / Preventatives Refills
One form per pet. If you have multiple pets, please fill out multiple forms
Name
*
First Name
Last Name
Pet Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How many prescriptions do you need filled?
*
1
2
3
Approximately when do you need the prescriptions(s) by?
*
-
Month
-
Day
Year
Please note it can take up to 72 business hours for our staff to receive and fill the prescription.
Questions, comments, or concerns?
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Prescription #1
Prescription #1 Name
*
For preventatives, please specify if it is NexGard, NexGard PLUS, Nexgard Combo, or HeartGard PLUS
Prescription #1 Dosage and Frequency
*
i.e. three 20mg tablets given twice a day
Prescription #1 Quantity to be filled
*
How is your Pet doing on this Prescription
*
Any noticeable changes both positive or negative?
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Prescription #2
Prescription #2 Name
For preventatives, please specify if it is NexGard, NexGard PLUS, Nexgard Combo, or HeartGard PLUS
Prescription #2 Dosage
i.e. three 20mg tablets given twice a day
Prescription #2 Quantity to be filled
How is your pet doing on this Prescription ?
Any noticeable changes both positive and negative?
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Prescription #3
Prescription #3 Name
For preventatives, please specify if it is NexGard, NexGard PLUS, Nexgard Combo, or HeartGard PLUS
Prescription #3 Dosage
i.e. three 20mg tablets given twice a day
Prescription #3 quantity to be filled
How is your Pet doing on this Prescription ?
Any noticeable changes both positive and negative?
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Next
Submit
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