Refill form

Patient Refill Request Form
Important Information About Your Pet's Prescription Refill
Refills are fulfilled Monday-Friday from 9 am-4 pm. Please allow up to 7 days for your refill to be approved and processed.
***Doctors cannot authorize prescriptions for patients who have not seen the doctor in the past 6 months.*** If you are unclear if your pet needs to schedule a recheck with the doctor please call (561-795-9398) or email us at flvetbehaviorservice@gmail.com .
Pet Parent Name:*
Email*
example@example.com
Preferred Phone Number*

Area CodePhone Number
Pet's Name*
Who is your pet's doctor?*

Dr. RadostaDr. AngDr. ColaretaDr. Grier
Medications

If your pet's medication is not listed in any of lists, you will have an opportunity to give that information in a field at the end of this document.
PLEASE NOTE:
1. Allow 7 days for refills to be processed.
2. The office can only call-in medications when there are extenuating circumstances such as emergencies, please contact us to see if we can call in your prescription.
3. We send prescriptions to the following online pharmacies: MixLab, Covetrus and Chewy.com.
4. For all other outside pharmacies, we will create a paper script for you to pick up or which will be mailed to you to bring to the pharmacy of your choice.
5. If your pet's doctor is out of the office, the refill request will be addressed when your doctor returns.
6. Emergency refills can only be filled for 7 days worth of medication.

Acepromazine tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
acepromazine 10 mg
acepromazine 25 mg

Adaptil Collar

	Within 48 hours	Within 5 days	Within 7 days	Refill quantity
Adaptil collar Sm-Med
Adaptil collar Med-Large

Calming Care

	Within 48 hours	Within 5 days	Within 7 days	Refill quantity
Calming Care for Dogs
Calming Care for Cats

Alprazolam Tablets Note-Legally we can authorize a maximum of 30 days worth of controlled substances with appropriate refills.

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
alprazolam 0.25 mg
alprazolam 0.5 mg
alprazolam 1.0 mg
alprazolam 2.0 mg

Buspirone Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
buspirone 5 mg
buspirone 15 mg
buspirone 30 mg

Clomicalm Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
Clomicalm 5 mg

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
Clomicalm 20 mg
Clomicalm 80 mg

Clonazepam Tablets Note-Legally we can authorize a maximum of 30 days worth of controlled substances with appropriate refills.

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
clonazepam 0.5 mg
clonazepam 1.0 mg
clonazepam 2.0 mg

Clorazepate Tablets Note-Legally we can authorize a maximum of 30 days worth of controlled substances with appropriate refills.

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
clorazepate 3.5 mg
clorazepate 7.5 mg
clorazepate 15 mg

Clonidine Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
clonidine 0.1 mg
clonidine 0.2 mg
clonidine 0.3 mg

Diazepam Tablets Note-Legally we can authorize a maximum of 30 days worth of controlled substances with appropriate refills.

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
diazepam 2 mg
diazepam 5 mg
diazepam 10 mg

Diazepam Tablets Note-Legally we can authorize a maximum of 30 days worth of controlled substances with appropriate refills.

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
lorazepam 0.5 mg
lorazepam 1.0 mg
lorazepam 2.0 mg

Escitalopram Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
escitalopram 5 mg
escitalopram 10 mg
escitalopram 20 mg

Fluoxetine Capsules

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
fluoxetine 10 mg

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
fluoxetine 20 mg
fluoxetine 40 mg

Fluoxetine Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
fluoxetine 10 mg
fluoxetine 20 mg
fluoxetine 40 mg

Gabapentin Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
gabapentin 25 mg
gabapentin 50 mg
gabapentin 100 mg quad tabs
gabapentin 600 mg
gabapentin 800 mg

Gabapentin Capsules

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
gabapentin 100 mg
gabapentin 300 mg

Galliprant Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
Galliprant 20 mg
Galliprant 60 mg

Guanfacine Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
guanfacine 1.0 mg
guanfacine 2.0 mg

Reconcile Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
Reconcile 8 mg
Reconcile 16 mg
Reconcile 32 mg
Reconcile 64 mg

Paroxetine Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
paroxetine 10 mg
paroxetine 20 mg
paroxetine 40 mg

Pregabalin Capsules Note-Legally we can authorize a maximum of 30 days worth of controlled substances with appropriate refills.

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
pregabalin 25 mg
pregabalin 50 mg
pregabalin 75 mg

Sertraline Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
sertraline 3 mg
sertraline 25 mg
sertraline 50 mg
sertraline 100 mg

Sileo Transmucosal Gel

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
Sileo

Solliquin Chewables

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
Solliquin Small-Med
Solliquin Med-Large

Trazodone Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
trazodone 50 mg
trazodone 100 mg
trazodone 150 mg

Zylkene Capsules

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
Zylkene 75 mg
Zylkene 225 mg
Zylkene 450 mg

Venlafaxine Tablets

	How many do you give at each dose?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
venlafaxine 25 mg
venlafaxine 50 mg
venlafaxine 100 mg

Please list any medications or formulations for which you are requesting a refill that are NOT listed above such as compounded medications. If the pharmacy is not listed, choose "other" and list the phone number below in the provided field.

	Medication	Formulation	How many do you give?	How often do you give the medication?	When will your pet run out of medication?	Pharmacy	Refill quantity
1
2
3

IF YOUR PHARMACY IS CVS, COSTCO, WALMART, or CHEWY.COM: Please note that these pharmacies do not permit prescriptions to be faxed, and for certain prescriptions, the pharmacy does not allow voicemail messages. We do not call prescriptions to any pharmacies, a written prescription must be picked up or mailed to you. Because of these limitations, it can take up to 3 days for a prescription to be received by the pharmacy. If you would rather pick up a written prescription to take to the pharmacy of your choice, please let us know.*

I understand.Does not apply.
We are only able to call prescriptions in to pharmacies on an emergency basis. A written prescription will be mailed to you or can be picked up for prescriptions being filled at a pharmacy. If you need your pet's prescription called into an outside pharmacy, provide the pharmacy number below. Please note call-ins are only being done in extenuating circumstances. If your pet has more than 5 days of medication left, a written prescription will be mailed to you.

Area CodePhone Number
In order to ship your pet's medications or written prescription, the fields below must be filled out. Medications will not ship, if the address isn't complete.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like us to collect payment?

You can pay over the phone or via a PayPal invoice that will be sent to your email. You do not need to have a PayPal account to pay via the PayPal invoice. There is an option on the invoice to pay with a debit/credit card. If you choose a phone call, we will call you only one time. We will leave a voicemail for you to call back.
Payment Method*

Phone CallElectronic InvoiceDoes not apply. (i.e. outside pharmacy)
How will you like to be informed that your pet's prescription is ready for pick up?*

Phone CallEmailTextDoes not apply. (i.e. outside pharmacy)
If we are shipping your pet’s medications, we must receive payment prior to shipping. NOTE: If you pay after 5PM, your package with be shipped the following business day.*

I understand.Medication is not being shipped.
List any medications prescribed for your pet by any veterinarian since your pet's last visit (to check for medication interactions). *
Should be Empty:

Patient Refill Request Form

Important Information About Your Pet's Prescription Refill

Medications

How would you like us to collect payment?