CO Rx Refill Form

NOTICE: Starting January 1st, 2019, we will no longer be calling medications into outside pharmacies. We cannot guarantee the quality of product or service from these locations, and to better serve our clients we will now be providing medications only through our clinic and our online pharmacy, Vets First Choice. We will also be happy to provide a written prescription for pick up or by mail for you to bring to the pharmacy of your choice, as it is the best way to ensure the accuracy of our prescriptions at outside pharmacies. In the event that the prescription refill is urgent and must be called into the pharmacy, a rush fee of $40 will be incurred.

Your First and Last Name *

Your Doctor *

Your Pet's Name *

Your pet's last known weight in pounds? (so we can alter dosage based on change in weight if necessary) *

Date last weighed? *

Medication being requested? *

Medication Format *

Capsules Tablets Liquid

Size/strength of tablet or capsule (mg) or liquid (mg/ml)? *

How many pills or mls at one time? *

How many times a day? *

Quantity needed for one month, i.e., # of tablets or capsules or # of mls for liquids? *

Is this medication helping? *

Yes, definitely Yes, some changes noted Not sure No

Describe any side effects noted. *

List any new medications or supplements prescribed by another vet (to check for drug interactions). *

We need at least 3 business days to refill prescriptions. If you need yours sooner, check yes. If you do not need the refill urgently, check no. If you cannot wait for a written prescription or delivery from our online pharmacy, Vets First Choice, a $40 rush fee will be charged to call into your pharmacy *

No Yes

Name and phone number of the pharmacy (only until 12/31/18, see notice at top of form). If online pharmacy, include web address. *

Behavior Vets of Colorado