First Regional Animal Hospital FIRST Regional
Animal Hospital


Chandler, AZ
(480) 732–0018
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Prescriptions Refill Request Form

Prescription Refill Request
Please fill in the form below. This prescription form is for use by clients whose pet we have examined within the past 12 months.

The prescribing veterinarian will review the request, and you will be contacted if it cannot be filled for some reason. An email confirmation will be sent for filled requests.

Client & Pet Information


*Pet Name:


*Address:


*State:


*Phone:


*Email:
*Client Name:


*City:


*Zip:


*Best Time to Call:


Please Select your Veterinarian:

Medications Requested:

Medication Name:
1.

2.

3.

4.

Dosage Size/Strength:








Quantity Requested:








Comments:


*Federal and State laws, as well as good medical practice, prohibit us from dispensing prescription medications without prior examination of your pet (within the last 12 months), and current knowledge of your pet’s health. We are similarly prohibited from dispensing or refilling medications that were originally ordered by another veterinarian. We will be happy to dispense any needed medications after examining your pet.

Kindly give us at least 24 business hours after submitting this form for us to fill your prescription request.

Please call us at (480) 732–0018 before you come in to be sure that your pet’s prescription is ready.




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