Name*

First Last

Phone*

Email*

Pet/Medication Information*

Pet Name	Name of Medication	Dosage Desired	Quantity Desired

Consent*

I agree to following:

I certify that I am at least 18 years old and I own the above-described pet(s)

By checking this box, it is your responsibility to make sure that you having the same medication(s) which you ordered, and the medication(s) label having the pet’s name and your last name before using it and give it to your pet.

Please allow the pharmacy at least 2 days to have the doctor’s approval and prepare the medicine.

Name

This field is for validation purposes and should be left unchanged.

Prescription Refill Request