Please complete the form below to request your pet’s medication

Your Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Name of Pet #1 (up to 3 pets per form)

Medications needed for Pet #1

List all medications and notes here for pet #1

Name of Pet #2

Medications needed for Pet #2

List all medications and notes here for pet #2

Name of Pet #3

Medications needed for Pet #3

List all medications and notes here for pet #3

Prescribing/Primary Doctor

Dr. Charlie Read Kydd

Dr. Shawn Day

Dr. Jinita Patel

Notes to doctor (optional)

How would you like to receive your medication?

*Controlled drugs cannot be shipped and must be picked up in person

I will pick it up after 24 hours

Please ship to me (additional $13.50)

If shipping, please confirm your shipping address

IMPORTANT:

Please allow a minimum of 24 hours to process your request, Monday thru Friday. If submitting your request on Saturday or Sunday, the earliest you may pick up is Tuesday morning. **PLEASE NOTE: You will not receive notification from our office when your medication is ready for pick up. If shipping option is selected, your medication will be shipped after 24 hours. By law, we are not permitted to ship controlled/monitored drugs; these must be picked up.

I understand

Questions? Give us a call at (609) 483-2590.

Prescription Request