Rx and Food Form – Chippawa Animal Hospital

Prescription Refill and Food Order Request Form

Please use the form below to request your prescription refill or food item. This will save you time when picking up your order. If we have all the information below we will notify you when the item(s) are ready for pick up, and arrange a specific time. If you wish to pay for the items over the phone, that will also streamline your visit. In good weather we can put some items outside just before you arrive along with your receipt.

IMPORTANT: Many prescriptions require your pet to be examined before dispensing. We wish to assess that the medication is appropriate, and that there are no changes in overall health to cause concern. Prescription Refills and Food Orders are not confirmed until you have received notification.

We charge a prescription fee for items that are ordered at a pharmacy. If you wish to be considered for automatic renewals please ask us about this.

Name*
First Last
Email*
Phone*
Pet Name*
Drug or Food Name*
Dosage/Size/Strength*
Quantity*
Are you giving any new medications or supplements?*
How is your pet doing with regards to response to this medication and in general?*

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