Prescription Refill Request Form

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.