Heal Pharmacy Request Form

Pharmacy Requests

Please note that prescription refill requests are only available for medications previously prescribed or recommended by Heal.
Client Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
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Patient Information
Pet Name*
Species*

DogCat
Medication Information
Medication Name*
Strength/Concentration*
(e.g., 5 mg, 25 mg/mL)
Dosage Instructions (How do you currently administer the medication?)*
Quantity Requested*
(number of tablets, mL, etc.)
Would you like to enable auto-refill?*
We offer free shipping for those who choose to auto-refill!
Has your pet experienced any side effects?*

YesNo
If yes, please describe.*
How would you like to receive your pet's medication?*

Pick up at HealShip it to me
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring/Primary Veterinarian Information

(if the prescription originated from another clinic)
Referring Veterinarian Name
Clinic Name
Clinic Phone
Please enter a valid phone number.
Clinic Email
example@example.com
Consent & Authorization
Note: We will send a text confirmation the same business day for any request submitted before 4:00 PM.
Prescription refills are subject to doctor approval and may require a recheck exam or updated bloodwork.*

I understand
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Pharmacy Requests

Client Information

Patient Information

Medication Information

Referring/Primary Veterinarian Information

Consent & Authorization