Please complete this short form to request a refill on a medication for your pet.

Please note: Regular prescription refills may take up to 1 week. Special order prescriptions may take up to 2 weeks. Same-day urgent refills have a $25 rush fee applied.

Name

First Name

Last Name

Pet's Name

Medication:

Current Directions

What is the concentration (mg/ml) or dose (mg), how frequently are you giving the mediation? **Please provide details to expedite the refill request. "Same as previous" will not be accepted and will delay processing.**

Supply Left

How many days supply do you currently have?

URGENT REFILL REQUESTED

Regular prescription refills may take up to 1 week. Special order prescriptions may take up to 2 weeks. Same-day urgent refills have a $25 rush fee applied.

Urgent Refill Requested - $25 fee will be applied

Quantity Requested

Number of units (ex. 15 tablets), or length of supply (ex. 1 month) **Please provide details to expedite the refill request. "Same as previous" will not be accepted and will delay processing.**

Update on your Pet

How is your pet doing generally? How is your pet doing on this dose of medication? Any other concerns? ****Please provide details to expedite the refill request. "Doing well" will not be accepted and will delay processing.**

To be filled by:

Please note: not all medications can be filled by human pharmacies

Olympic Village Vet

Outside/Human Pharmacy

Human Pharmacy Contact Information

At minimum, pharmacy name and address (ex. London Drugs in Olympic Village). Fax number appreciated if known.