{"id":483,"date":"2025-02-07T20:09:24","date_gmt":"2025-02-07T20:09:24","guid":{"rendered":"https:\/\/classenviewvet.com\/?page_id=483"},"modified":"2025-02-08T00:07:38","modified_gmt":"2025-02-08T00:07:38","slug":"prescription-refill-request-2","status":"publish","type":"page","link":"https:\/\/classenviewvet.com\/index.php\/prescription-refill-request-2\/","title":{"rendered":"Prescription Refill Request"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-8cb0ff34-1148-4222-a503-64aff383e549 wpforms-render-modern\" id=\"wpforms-485\"><form id=\"wpforms-form-485\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"485\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/483\" data-token=\"4d3c6fc5aef0e24166b0b5df7b568dfa\" data-token-time=\"1777044034\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-485-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_1\">Patient&#039;s Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-485-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-485-field_1-error\" required><\/div><div id=\"wpforms-485-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"2\"><fieldset><legend class=\"wpforms-field-label\">Client&#039;s Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-485-field_2\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][2][first]\" aria-errormessage=\"wpforms-485-field_2-error\" required><label for=\"wpforms-485-field_2\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-485-field_2-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][2][last]\" aria-errormessage=\"wpforms-485-field_2-last-error\" required><label for=\"wpforms-485-field_2-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div>\t\t<div id=\"wpforms-485-field_6-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"6\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-485-field_6\" >This The The<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-485-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-485-field_3-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_3\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-485-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" spellcheck=\"false\" aria-errormessage=\"wpforms-485-field_3-error\" required><\/div><div id=\"wpforms-485-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_4\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-485-field_4\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"+1 (999) 999-9999\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-485-field_4-error\" required><\/div><div id=\"wpforms-485-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_5\">Best Number To Reach You Regarding This Request? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-485-field_5\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"+1 (999) 999-9999\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-485-field_5-error\" required><\/div><div id=\"wpforms-485-field_17-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Has Your Pet Been Seen By A Veterinarian At Classen View Clinic In The Last 6 Months? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-485-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-485-field_17_1\" name=\"wpforms[fields][17]\" value=\"Yes\" aria-errormessage=\"wpforms-485-field_17_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-485-field_17_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-485-field_17_2\" name=\"wpforms[fields][17]\" value=\"No\" aria-errormessage=\"wpforms-485-field_17_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-485-field_17_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-485-field_18-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Is This Request For A Long Term Medicine Your Pet Is On? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-485-field_18\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-485-field_18_1\" name=\"wpforms[fields][18]\" value=\"Yes\" aria-errormessage=\"wpforms-485-field_18_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-485-field_18_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-485-field_18_2\" name=\"wpforms[fields][18]\" value=\"No\" aria-errormessage=\"wpforms-485-field_18_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-485-field_18_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-485-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_8\">What Is The Name Of The Medication You Would Like Refilled? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-485-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-485-field_8-error\" required><\/div><div id=\"wpforms-485-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_9\">What Is The Strength\/Concentration Of The Medication (Example: 100mg or 1.0 mg\/mL) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-485-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-485-field_9-error\" required><\/div><div id=\"wpforms-485-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_10\">How Often Are You Giving The Medication? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-485-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-485-field_10-error\" required><\/div><div id=\"wpforms-485-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_11\">Has There Been Any Recent Changes In Giving This Medication? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-485-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-485-field_11-error\" required><\/div><div id=\"wpforms-485-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_12\">How Many Months Would You Like To Order? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-485-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-485-field_12-error\" required><\/div><div id=\"wpforms-485-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_14\">If This Prescription Request Is For An Outside Pharmacy, Please Include The Name Of The Pharmacy, Address, Email, Fax, And Phone Number. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-485-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-485-field_14-error\" required><\/div><div id=\"wpforms-485-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-485-field_13\">Additional Information:<\/label><input type=\"text\" id=\"wpforms-485-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-485-field_13-error\" aria-describedby=\"wpforms-485-field_13-description\" ><div id=\"wpforms-485-field_13-description\" class=\"wpforms-field-description\">Please Add Any Additional Information You Feel Is Pertinent To This Prescription. <\/div><\/div><div id=\"wpforms-485-field_16-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">I Understand That It Will Take 24 Business Hours For All Prescriptions To Be Reviewed By Our Team, Approved Or Declined By Our Veterinarian. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-485-field_16\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-485-field_16_1\" name=\"wpforms[fields][16][]\" value=\"Yes\" aria-errormessage=\"wpforms-485-field_16_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-485-field_16_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-485-field_6-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-485-field_6-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-485-field_6-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"485\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages\/483\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-485\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/classenviewvet.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\n\n<p><strong>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.<\/strong><\/p>\n\n\n\n<p><strong>If you would like to pick up the prescription to take to your pharmacy, please indicate this above in the additional information area. <\/strong> <\/p>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-483","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages\/483","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/comments?post=483"}],"version-history":[{"count":2,"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages\/483\/revisions"}],"predecessor-version":[{"id":494,"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages\/483\/revisions\/494"}],"wp:attachment":[{"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/media?parent=483"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}