Prescription Form

Disclaimers

(1) All refills are subject to approval by DVM; subject to the appropriate recheck interval and recommended blood work if required (for instance we recommend a CBC every 2 months for patients on leukeran, every 3 weeks for patients on Lomustine quarterly for the first year for patients on long term NSAID, etc.); must have been seen within the last year, and we may not fill for meds other than those conditions for which we have actually seen the patient (i.e. can't refill thyroid med if we have not treated the patient for this problem and have no records of the therapy protocol).

(2) This service is provided 9am - 4pm Monday through Friday. Routine refills are not available on the weekends.

(3) Please allow 1 - 2 working days for delivery of most medications.

(4) Compounded medications may take up to 7 days if the quantity required is not in stock.

Clients Name (first, middle, last): *

VMSG Account Number (if known):

Best Daytime Phone number: *

Alternate Phone Number:

Pet's Name:

Drug Name (as it appears on the Rx label): *

Drug Strength (mg, mcg, mg/ml):

Current form, dose and frequency this drug is being given?
(please select just one of the following options)

Tablets & Capsules

Form:

Quantity:

Frequency:

Frequency of dosage (daily)

Oral Liquids

Quantity:

Frequency:

Frequency of dosage (daily)

Metered Dose Inhaler

Quantity:

Number of puff(s) per dose

Frequency:

Frequency of dosage (daily)

Topical

Frequency:

Frequency of dosage (daily)

Eye Drops

Quantity:

Number of drop(s) per dose

Frequency:

Frequency of dosage (daily)

Affected Side:

Eye Ointment

Quantity:

Number of inches per dose

Frequency:

Frequency of dosage (daily)

Affected Side:

Ear Drops

Quantity:

Number of drop(s) per dose

Frequency:

Frequency of dosage (daily)

Affected Side:

Other

Form:

Dose:

Frequency:

Quantity requested per refill:

Note: If you have refills on file and are requesting a larger refill quantity and it exceeds the total of the remaining refills, we will fill the requested quantity once the specialist has approved the increase. This may delay the pick up time. If this increased quantity will delay the prescription or if it is not approved, we will call or email with a notification

Number for refills being requested:

This number may not exceed a one year supply from the date of your last visit for the condition being treated

Regular Veterinarian Info

Regular veterinarian or pharmacy name and phone number if this is to be filled by someone other than VMSG

Veterinarian or Pharmacy Name:

Phone # (with area code):

Rx # (if refill is to a human pharmacy):

Urgency for refill:

Please enter day(s) of medication remaining

Do you need another medication for this pet?:

Yes

Do you need a refill for another pet?:

Yes

When would you like to pick up this medication?:

Please enter a date

Delivery Options

We do not routinely ship items. For our long distance clients the following shipping charges apply:

USPS $5.95 for most items (this is weight dependent and excludes food and treats).
FedEx overnight is available Monday thru Thursday (based on FedEx pricing this can cost $25.95 and up)

Do you desire to have this shipped?:

Yes

Shipping Method:

USPS Ground

FedEx Overnight

Shipping Address

Street:

Suite/Unit #:

City:

State:

Zip:

Comments:

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