Pharmacy Refill Request Page

1. Client and Patient Information
* First Name: *
* Last Name: *
* Pet's Name: *
Case Number:
* Home Phone: *
Cell Phone:
Work Phone:
E-mail Address
If you would like confirmation regarding completion of your order, please provide your e-mail address.

2. Prescription Information
1. RX #		Name of Medication
2. RX #		Name of Medication
3. RX #		Name of Medication
4. RX #		Name of Medication
5. RX #		Name of Medication

3. Select one Delivery Option
Please allow at least 1 Business day for refills. Please allow at least 2 Business days for compounded medications or medications with no refills remaining.
Pickup Mailing	Pickup From:  Select One Small Animal Large Animal   Refrigerated items only shipped Monday-Thursday excluding holidays. Must be sent next day.Next Day $17.00 - No PO Boxes Second Day $13.00 - No PO Boxes First Class $7.50 Note: On First Class, packages cannot be tracked and shipment will NOT be replaced without charge if lost.
Street
Street 2
City
State	AK AL AR AZ CA CO CT DE FL GA HI ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code

4. Comments (Special Instructions)

                              
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