RX Refill - Veterinarian and Animal Hospital in Polson, MT

You can email prescription refill requests and pick them up and pay for them at the clinic. If you are an established client whose pet has been seen within the last year and we have your credit card information on file, we can ship prescription refills or flea and tick medications to you (shipping and handling charge will be added to your order). Please provide your name, your pet’s name and the medications you need.”

CLIENT AND PATIENT INFORMATION
Your Name*
First Last
Pet's Name*
Date Requested*
MM slash DD slash YYYY
Email*
Phone*
Best Time To Call*
Alternate phone number*
Receiving the Meds*
REQUESTED PRESCRIPTION REFILLS
Please list the names, dosages and quantities of the medication(s) you are requesting.
List the name of prescriptions
Medication Requested Dosage Size/ Strength Quantity Requested
YOUR PET'S CURRENT MEDICATIONS
Please list the names and amounts of any medication your pet is currently receiving. Also include the time your pet last received each medication.
List the name of prescriptions
Medication Given Dosage Size / Strength Time of Last Dose
COMMENTS
If you have noticed any changes in your pet’s health or behavior, please comment in the box below.

Medication Requested	Dosage Size/ Strength	Quantity Requested

Medication Given	Dosage Size / Strength	Time of Last Dose

CLIENT AND PATIENT INFORMATION

REQUESTED PRESCRIPTION REFILLS

YOUR PET'S CURRENT MEDICATIONS

COMMENTS