Medication Refill Request Form in Studio City, CA | Animal Vision Care & Surgical Center

Current clients may use this form to refill their pet’s medication. An email will be sent to our office. A team member will reply to the contact information within 24 business hours (Monday-Thursday). Alternatively, you may call, text, or email your request.

***By federal law, we cannot refill a prescription if we have not examined your pet in the past year***

This form will disappear when successfully submitted and an email confirmation will be sent to your provided email address (if one was provided).

Name*
First Last
Patient Name*
Phone*
Email
We will let you know when the medication order is processed. What is your preferred method of contact?
- Phone - Call
- Phone - Text
- Email (Must provide an email address)
How would you like to receive your medication?*
- I'll pick it up at the clinic.
- Please send the prescription to a pharmacy near me.
If you'd like the prescription sent to a pharmacy, which one?
Please note, compounded medication prescription cannot sent to a regular pharmacy. (Examples: Tacrolimus, Cidofovir, Idoxuridine & EDTA eye drops)
Medication(s) requested:
Example: 2 bottles of Dorzolamide and 1 tube of Optimmune
How would you like to pay?
- I will pay upon pick-up of the medication at the clinic
- Call me to pay in advance for another person to pick up
- I will contact the clinic
Verification
Company
This field is for validation purposes and should be left unchanged.

Medication Refill Request Form

This form will disappear when successfully submitted and an email confirmation will be sent to your provided email address (if one was provided).

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