Prescription Refill

If you are ordering from an online pet pharmacy such as Chewy or 1-800-Pet-Meds then you do NOT need to complete this form as they will contact us once you initiate the order.

This form is for human pharmacy refill requests or pick-up at MVP.

Please allow 72 hours for refill requests.

**Per the Drug Enforcement Agency, pets must be current on annual exams to receive refills**

Client Name*

First NameLast Name

Pet Name*

E-mail*

Prescription Name*

Prescription Strength (usually in mg)*

How often is this medication given?*

Quantity (the # of pills you want):*

Where would you like this filled?*

MainstayOutside Pharmacy

Pharmacy Name*

Pharmacy Location*

Pharmacy Fax Number*

Area CodeFax Number