Prescription Refill Request Form
Please fill this form out completely and accurately to help us expedite your prescription refill requests as timely as possible. Thank you.
Prescription refill requests are processed 9 am to 5 pm, Monday-Friday
Requests submitted outside these hours will be processed the next business day. Please submit refill requests at least 7 business days before you need the medication filled.
Today's Date
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Month
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Day
Year
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Your Name
*
First Name
Last Name
Email
*
example@example.com
Pet's Name
*
Please list the medication(s) you are requesting for refill:
Please list which medication(s) you are requesting to be refilled. Please list medication(s) you are requesting to be refilled. PLEASE ANSWER FILL IN EACH COLUMN. Forms received without all columns answered will be processed as standard refill requests, which may take up to 7 business days to process
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Rows
Medication Name
Strength & Form e.g. 20mg tablet
Pills per dose e.g.1
Frequency per day
e.g. twice
Time(s) of Day Given
e.g. 8am / 7pm
Day Supply Remaining
e.g. 10 days
Quantity requesting for refill in pills
e.g. 180 tablets
1st
2nd
3rd
4th
Is this request urgent? (For example, you are out of your pet's current medication and need a refill within 2 business days.)
*
This request is urgent - I need a refill within 2 business days.
This request is not urgent - I understand it may take 3 or more business days to process
Where would you like this prescription filled?
*
Local human pharmacy **Note: Human pharmacies will not carry canine-specific medications such as Reconcile or Clomicalm)
Primary veterinary clinic
Compounding Pharmacy
Other - if selected, please provide the name and number of your preferred pharmacy
Please provide the name of the local human pharmacy of your choice
Please provide the phone number of the local human pharmacy of your choice
Please enter a valid phone number.
Format: (000) 000-0000.
Please provide the name of your primary veterinary clinic
Please provide the phone number of your primary veterinary clinic
Please enter a valid phone number.
Format: (000) 000-0000.
Please provide the name of the compounding pharmacy of your choice
Please provide the phone number of the compounding pharmacy of your choice
Please enter a valid phone number.
Format: (000) 000-0000.
If applicable, please include any information pertinent to this refill or medication you'd like us to know:
Submit
Should be Empty: