In Clinic Prescription Refill

In an effort to streamline our processes, please request any in clinic refills through our website using the form below.

Please allow 24-48 business hours to process your requests.

General Information

First Name *

Last Name *

Email Address *

Phone *

Preferred method of contact

Pet #1

SpeciesDogCat

Pet's Name

Drug Name

Strength (How many mgs/mls)

Current Dosing (1 tablet twice a day, 1 ml by mouth once a day, etc)

When would you like to pick up?

Pet #2

Pet #3

Pet #4

Other Information

Please Read - Financial Responsibility

For your convenience, we will accept payment in the form of Cash, Check, Visa, Mastercard, American Express and Discover. By submitting this form, I agree I am responsible for any charges incurred by my pet and that payment is due at the time of service. Delinquent accounts will be assessed interest at a rate of 18% per annum. Should it become necessary to place a delinquent account with a collection agency, a collection fee of up to 35% of the principle balance due will be added to defray the cost of collection. Additionally, if legal action is necessary to collect the delinquent account I/we understand that I/we will be responsible for all costs of collection to include but not limited to court costs, interest, and attorney fees. In any of these events, a credit report may be pulled.

Authorized Signer *

Date *