Refill Request

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   Please note that prescription drugs may only be dispensed to a client of the Manotick Veterinary Hospital for a pet currently under our medical supervision.

     This form will allow you to refill up to two prescriptions.  If further prescription refills are necessary, please return to this page and submit a new form. Please bookmark this page for the next time a drug refill is necessary.

     * Denotes a required field.

Contact Information

Please enter your e-mail address: *
Last name: *
First name:
Work phone:
Home phone:

First Refill

Pet's name:

Drug or product name:

Please select the form of the drug:



PLEASE FILL IN ONLY ONE OF THE FOLLOWING FIVE FIELDS:

(1) Tablets, Capsules or Chews

For tablets, capsules or chews please, indicate the mg or grams per tablet, capsule, or chew:


For tablets, capsules or chews, please indicate the number requested:




(2) Topical Sprays, Creams and Ointments

For topical sprays, creams and ointments (including ear ointments), please indicate the grams or mLs per container:


For topical sprays, creams and ointments, please indicate the number of tubes or bottles requested:




(3) Oral Suspensions/Liquids and Transdermal Gels

For oral suspensions/liquids and transdermal gels, please indicate the mgs or grams per mL:


For oral suspensions/liquids and transdermal gels, please indicate the total number of mLs requested:




(4) Powders

For powders, please indicate the total number of mgs or grams requested:




(5) Injectable Drugs

For injectable drugs, please indicate whether you would like multiple syringes or a full bottle:

Multiple Syringes
Bottle

If multiple syringes, please indicate how many how would like prepared:


Additional Information

Please select an authorizing veterinarian:


Please tell us when your pet will run out of medication:


Special instructions or requests (for example, flavour of chews, or insulin syringes for a diabetic pet):



     If you have only one refill request, please scroll to the bottom of the page to submit your order.  Otherwise, you may continue with the form.

Second Refill

Pet's name:

Drug or product name:

Please select the form of the drug:



PLEASE FILL IN ONLY ONE OF THE FOLLOWING FIVE FIELDS:

(1) Tablets, Capsules or Chews

For tablets, capsules or chews please, indicate the mg or grams per tablet, capsule, or chew:


For tablets, capsules or chews, please indicate the number requested:




(2) Topical Sprays, Creams and Ointments

For topical sprays, creams and ointments (including ear ointments), please indicate the grams or mLs per container:


For topical sprays, creams and ointments, please indicate the number of tubes or bottles requested:




(3) Oral Suspensions/Liquids and Transdermal Gels

For oral suspensions/liquids and transdermal gels, please indicate the mgs or grams per mL:


For oral suspensions/liquids and transdermal gels, please indicate the total number of mLs requested:




(4) Powders

For powders, please indicate the total number of mgs or grams requested:




(5) Injectable Drugs

For injectable drugs, please indicate whether you would like multiple syringes or a full bottle:

Multiple Syringes
Bottle

If multiple syringes, please indicate how many how would like prepared:


Additional Information

Please select an authorizing veterinarian:


Please tell us when your pet will run out of medication:


Special instructions or requests (for example, flavour of chews or insulin syringes for a diabetic pet):




 

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Site created by Dr. Heather Ann Matheson-Rakita.  Copyright 2003 Manotick Veterinary Hospital. Last modified: February 02, 2004