schedule

Rocky Gorge Animal Hospital Prescription Medication and Diet Refill Requests

*required fields.

  • CLIENT AND PATIENT INFORMATION

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

  • Please complete one medication and diet refill per pet. If all items are for the same pet, they may be submitted on one form.

  •

  • Please note
    Shipping and handling charges will apply for shipped medications.

    We will not ship controlled substances.

    We reserve the right to decline shipping services based on size, weight, or other factors.

    Please note, at this time Rocky Gorge Animal Hospital cannot mail or ship diet(s).

  • REQUESTED PRESCRIPTION MEDICATION REFILLS

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

  • Medication Requested Dosage Size/
    Strength    		 Pills
    or Liquid    		 Quantity or
    Amount Requested
    Drug 1:
    Drug 2:
    Drug 3:
    Drug 4:

  • REQUESTED DIET REFILLS

  • Please list the names, brand, canned or dry, size of bag or cans, and quantities of the diet(s) you are requesting. Please list canned and dry items on separate lines.

  • Name of Diet Requested Brand of Diet Canned or Dry Size of Bag
    or Cans    		 Quantity Requested
    Diet 1:
    Diet 2:
    Diet 3:
    Diet 4:

  • *MEDICATION(S) YOUR PET IS CURRENTLY RECEIVING.

  • Please list the names and amounts of any medication your pet is currently receiving. Also include the date and time your pet last received each medication.

  • Medication Given Dosage Size/
    Strength    		 Pills or Liquid Date and Time
    of Last Dose
    Drug 1:
    Drug 2:
    Drug 3:
    Drug 4:

  • COMMENTS AND QUESTIONS