Prescription Refill Request

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Please complete the following form if you wish to request a refill for your pet's prescription. We will respond to your request within one business day by phone or e-mail to confirm the order and discuss your preferred pick-up location. If you have any questions please feel free to call us at 610.435.1553. Please note that a veterinarian from our office must have prescribed the original prescription.

Name*

E-mail

Phone*

Address

Address2

City

State: Select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Pet's Name*:

Veterinarian*:

Prescription Refill Information

Drug Name*:

Strength*:

Quantity*:

Delivery Information

How would you like the requested prescription(s) delivered?
Pick up at VCVREC    
Pick up at local pharmacy    
Mail - VCVREC will call to confirm submission and availability

Do you have any additional comments?