Affiliated Veterinary Specialists

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Prescription Refill Request Form

* Marked fields are required.

Date Submitted:
  
* Your Name:
 * Your Pet's Name:
* Address:
* City, State, Zip:
Email Address:
 * Best Phone Number(s) to reach you:
Please note: Medication can not be prescribed for a patient who has not been seen by one of our doctors within the last 6 months.
Medication(s) Requested:
 Pick up at AVS
 Call into pharmacy
Pharmacy Name:
 Pharmacy Phone Number:
Requested pick up date:
                                                                                                
Please allow 3 business days to process your request.
 

 

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