Animal Owner Refill Request

CONTROLLED SUBSTANCE PRESCRIPTIONS MUST BE GIVEN BY PHONE, FAX, OR ESCRIBE ONLY

Animal Owner Refill Request Form

Owner Name *

First

Last

Email *

Phone *

RX Number *

Drug Name *

Do you have another RX?

Yes
No

Name As it Appears on Credit Card *

Credit Card Number (without dashes) *

Expiration Date on Credit Card *

CVC Code on Back of Card *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Select a Shipping Option *

Is Shipping Address Different that Billing Address? *

Yes
No

Additional Comments

Disclaimer

I Understand (Check the Box)

* All prices are subject to change, due to the cost of the raw drug. * All shipping methods are subject to change, we want to ensure that your medications are coming to you in the best condition, in order to do this sometimes we have to upgrade your shipping method.

After You Submit your Refill Request

We'll contact you as soon as possible to confirm your order. We'll send you an email confirmation with a printable order summary.