Prescription Refill Request

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Patient's Name *

Client's Name *

First

Last

Email *

Phone Number *

Best Number To Reach You Regarding This Request? *

Has Your Pet Been Seen By A Veterinarian At Classen View Clinic In The Last 6 Months? *

• Yes
• No

Is This Request For A Long Term Medicine Your Pet Is On? *

• Yes
• No

Changes Address, Veterinarian

What Is The Name Of The Medication You Would Like Refilled? *

What Is The Strength/Concentration Of The Medication (Example: 100mg or 1.0 mg/mL) *

How Often Are You Giving The Medication? *

Has There Been Any Recent Changes In Giving This Medication? *

How Many Months Would You Like To Order? *

If This Prescription Request Is For An Outside Pharmacy, Please Include The Name Of The Pharmacy, Address, Email, Fax, And Phone Number. *

Additional Information:

Please Add Any Additional Information You Feel Is Pertinent To This Prescription.

I Understand That It Will Take 24 Business Hours For All Prescriptions To Be Reviewed By Our Team, Approved Or Declined By Our Veterinarian. *

• Yes

Submit

Please allow 24 business hours for outside pharmacy requests to be emailed/faxed to the applicable pharmacy. We will not contact any pharmacy by phone to approve prescriptions.

If you would like to pick up the prescription to take to your pharmacy, please indicate this above in the additional information area.