Medication Refill Request

Please fill out this form and we will contact you regarding your prescription refills within 24 hours.

The prescription must be approved by a doctor. You will be notified when your prescription is ready for pickup.

If you need your pets medication in less than 24 hours please complete your request by telephone ((763) 784-9581).

Underlined fields are required.

CLIENT AND PATIENT INFORMATION

REQUESTED PRESCRIPTION REFILLS

Please list the names, dosages and quantities of the medication(s) you are requesting.

Medication Requested Dosage Size / Strength Quantity Requested
Drug 1:
Drug 2:
Drug 3:
Drug 4:

VERIFICATION

Image Verification

Duplicate the code to the left (Case Sensitive)