Pharmacy Refill Online Form
***Please allow 24-48 hours to complete your request. We will reach out when your request is complete and ready for pick-up. We appreciate your patience. ***
Location to Fill Prescription At
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Please Select
West Loop
Streeterville
Owner's Name
*
First Name
Last Name
Preferred Phone Number
*
Preferred Email
*
Pet's Name
*
Medication Name
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Strength (Ex: 25mg or 5mg/ml)
*
How much and how often is the medication given (Ex: 2 tablets every 12 hours)
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Do you have additional prescriptions that need filled?
Yes
No
Is this for the same pet as listed above?
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Yes
No
Pet Name
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Medication Name
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Strength (Ex: 25mg or 5mg/ml)
*
How much and how often is the medication given (Ex: 2 tablets every 12 hours)
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Where does the prescription need to be filled?
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Pick-up from WLVC
Fill my prescription and mail it to me (local and non-controlled substances only)
Alternate Pharamcy
** Please allow up to 10 business days for delivery as USPS is experiencing significant delays. **
Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Name
*
Pharmacy Number
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-
Area Code
Phone Number
How would you like to be contacted with updates regarding the prescription
*
Phone Call
Text
Email
Upload a photo of your Pet's Prescription (Please click upload after selecting the image)
Additional Comments:
Please verify that you are human
*
Submit
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