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

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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
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Medication Refill Request Form