Refill Request Form

Save time getting your next prescription! Complete our online refill form and our pharmacist will review your request.

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Refill Request Form

Please fill out this form as completely and accurately as possible so we can more easily streamline the refill process.

Client and Patient Information

Client Name *

First

Last

Email *

Phone *

Best Time To Call *

May we text you? If so, what number can we text you at? *

Pet's Name *

Date Requested *

I understand the 72-hour turnaround timeframe: *

Yes

By selecting YES - I am agreeing that my pet can wait AT LEAST 72 hours for these medications and that I understand that all medication refills MUST go through a veterinary and that time frame can take up to 72 hours before my pets chart can be reviewed. If this is an URGENT REFILL, please call us at (541) 924-1700.

REQUESTED PRESCRIPTION REFILLS

Please list the names, dosages and quantities of the medication(s) you are requesting.

List the name of prescriptions

Medication Requested

Dosage Size/ Strength

How much are you giving and How Often

Quantity Requested

How is Medication Given (by mouth, subcutaneously, rectally, applied to skin, applied to ears, or other -- if other, please explain)

How is your pet doing on this medication? Do you have any concerns about this medication?

Your Pet's Current Medication

Please list the names and strengths of any other medication your pet is currently receiving.

Comments

If you have noticed any changes in your pet’s health or behavior, please comment in the box below.

Refill Request Form

Refill Request Form

Client and Patient Information

REQUESTED PRESCRIPTION REFILLS

List the name of prescriptions

Request an Appointment

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Location

Contact Information

Hours