Haines Road Animal Hospital - Prescription Refill Request

Patient Information ----------------------------------------------------------------------------------------
First Name:
Last Name:
Pet's Name:
Phone #:
eMail:

Please Choose Your Veterinarian:


Prescriptions Requested ----------------------------------------------------------------------------------------
Medication Requested	Dosage Size / Strength	Quantity Requested
Name:
Name:
Name:
Name:

Comments

* Federal and State laws, as well as good medical practice, prohibit us from dispensing prescription medications without prior examination of your animal (within the last 12 months), and current knowledge of your animal's health. We are similarly prohibited from dispensing or refilling medications that were originally ordered by another veterinarian. We will be happy to dispense any needed medications after examining your pet. Kindly give us at least 24 business hours after submitting this form. Please call before you come to be sure that your pet's prescription is ready. Let us know if you would like your prescription mailed. We will call you for a credit card number. The packaging and mailing fee is $8.50 for most prescriptions.

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