prescription refill request form

Please complete the form below to request the item you would like to pick up. Make sure to complete all required fields. If you do not know the dosage, put your pet’s current weight instead. If ordering food, put the bag size in the dosage section. In the “quantity requested” section, put the number of doses (tablets, tubes, etc.) requested.

If you know your account number, you can put that in the “comments” section along with any special instructions and note of your pet’s progress.

Please submit a separate request for each patient.

In order for us to dispense any prescription medication, you pet must be a current patient and have been seen within the past 12 months by one of our veterinarians.

Click here to view a list of available discounts and rebates on items we carry.

*required fields

client and patient information

*your first name:

*your last name:

*your pet's name:

*email address:

*phone:

alternate phone:

requested prescription refills

*meds requested *dosage (mg) *qty requested

drug 1:

drug 2:

drug 3:

drug 4:

your pet's current medications

meds given dosage (mg) qty requested

drug 1:

drug 2:

drug 3:

drug 4:

progress report

Has your pet had any of the following?

*1. behavioral changes?

*2. diarrhea or vomiting?

*3. constipation?

*4. changes in urination?

*5. sneezing?

*6. coughing?

*7. stiffness or lameness?

yes no
yes no
yes no
yes no
yes no
yes no
yes no

8. other? please explain:

additional comments or questions: