202 Frank Scott Parkway East  Swansea, IL 62226 (618)222-9860

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PRESCRIPTION REFILL REQUEST


If you are currently a client and we have prescribed a medication (including heartworm and flea meds, as well as prescription food) for one of your pets, you can submit this form to request a refill of that prescription. We will then contact you within 1 business day to let you know if, and when, it’s ready. If you are requesting refills for more than 1 pet, you will need to submit a form for each pet. Please note that refills for controlled drugs must be requested 4 business days prior to when we need to have them ready for you.

Form - Prescription Refills Online

Name (required)
First Name (required)
Last Name (required)
Pets Name
First Name
Last Name
Phone
Phone TypePhone Number
Alternate Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Do you prefer that we contact you regarding the prescription by (required)
Phone
Email

Do you prefer to pick the medication up or have it mailed* to you:
Pick Up
Mail


* mailing via the USPS will incur an additional charge determined by product size & weight
Requested Prescription(s)
Medication Description #1
Name of Medication

Dosage Size/Strength

Form of Medication :
Quantity Desired

Medication Description #2
Name of Medication

Dosage Size/Strength

Form of Medication :
Quantity Desired

Medication Description #3
Name of Medication

Dosage Size/Strength

Form of Medication :
Quantity Desired

Medication Description #4
Name of Medication

Dosage Size/Strength

Form of Medication :
Quantity Desired

Current Medications

Please list the names & dosages of all drugs or nutritional supplements your pet currently takes & day of last dose.
Current Medication Description #1
Name of Medication

Dosage Taken

Date of Last Dose

Current Medication Description #2
Name of Medication

Dosage Taken

Date of Last Dose

Current Medication Description #3
Name of Medication

Dosage Taken

Date of Last Dose

Current Medication Description #4
Name of Medication

Dosage Taken

Date of Last Dose

Progress Report:

Has your pet had any of the following within the past week?
Behavioral changes?
Yes
No

Please Describe

Changes in appetite?
Yes
No

Please Describe

Diarrhea or vomiting?
Yes
No

Please Describe

Any other concerns?
Yes
No

Please Describe


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