G-4KF03473NY

Prescription Refill Request

This form is for established clients and patients at Loyal Family Veterinary Hospital.

Requests will not be processed or approved without a current valid client-patient-veterinarian relationship

or for new medications your pet has not been previously prescribed or currently taking.

Complete the following form to request up to three (3) prescription refills for one (1) pet.

If you are requesting medications for more than one (1) pet, please submit a new request for each pet.

Please do not request prescription refills for more than one pet on the same form.

Once we receive your request, we will reach out when your prescriptions are ready or if we have any questions.

All prescription requests are subject to veterinarian approval and may require an exam.

**Please allow up to 72 business hours for request to be processed**

Prescription Refill Request

Client Name (First and Last):

Email:

Phone:

space

Pet's Name:

This pet is a current patient at Loyal Family Vet

Yes

If no

If No, cancel this request and complete the New Client From to establish as a client and make an appointment.

Any Allergies to Medication?:

Yes

Unknown

If Yes, what medication?:

space

1. Name of Medication:

Strength / Size of Medication (mg, ml, etc.)

Current Dose / How much is medication given? (1 tablet, 1/2 tablet, 1ml, etc.)

How often medication is given? (once daily, every 12 hours, once monthly, etc.)

How many doses / days supply would you like? (requests will be reviewed and approved by a doctor)

space

2. Name of Medication

Strength / Size of Medication (mg, ml, etc.)

Current Dose / How much is medication given? (1 tablet, 1/2 tablet, 1ml, etc.)

How often medication is given? (once daily, every 12 hours, once monthly, etc.)

How many doses / days supply would you like? (requests will be reviewed and approved by a doctor)

space

3. Name of Medication

Strength / Size of Medication (mg, ml, etc.)

Current Dose / How much is medication given? (1 tablet, 1/2 tablet, 1ml, etc.)

How often medication is given? (once daily, every 12 hours, once monthly, etc.)

How many doses / days supply would you like? (requests will be reviewed and approved by a doctor)

space

Pick Up Medication or Written Prescription to take to a pharmacy?

Pick Up at Loyal Family

Written Prescription

space

When ready, how would you like us to notify you?:

Phone Call (listed above)

Email (listed above)

Address: 677 120th Ave NE, Bellevue WA 98005 |

Phone: 425-201-1908

Website: www.LoyalFamilyVet.com

Traditional & Integrative Veterinary Services

Monday - Friday: 7:30am - 6:00pm, Saturday: 9:00am - 4:00pm

Address: 677 120th Ave NE, Bellevue WA 98005 |

Phone: 425-201-1908

Website: www.LoyalFamilyVet.com

Monday - Friday: 7:30am - 6:00pm

Saturday: 9:00am - 4:00pm