Use this form to request a refill for a prescription. We will notify you of your refill via e-mail. You should receive a confirmation e-mail within 24-36 hours. If not, give us a call.

  • Federal Law prohibits the dispensing of certain medications without examination or prescription.
  • Due to the new Arizona Pharmaceutical Statue, the owners date of birth is required if a controlled substance is to be dispensed. Please call with any questions or concerns with this matter.
  • Some prescriptions may require annual/bi-annual bloodwork prior to dispensing.
  • Some prescriptions may be available at your local pharmacy. Please call for details.

Owner Information

Owner Name Co-Owner Name
First     First
Last     Last
Client #  
Address
Address   City  
State   Zip Code   
Telephone     e-Mail    
What's This?

Pet Information

Pet Name  
List Refill Medication(s)  
Please add any notes regarding your prescription:

Request Date and Time

Note: Please use calendar to select date
Provide desired date to pick up prescription:
   
Provide desired time to pick up prescription: