Prescription Refill and Food Order Request Form – Main Street Veterinary Services

Prescription or Product Refill Request Form

Thank you for your utilizing our refill ordering system. All of the required fields must be completed in order to successfully submit this form. If one or more area is missed, you will be unable to submit and the missing answer(s) will be highlighted in red. You will need to complete the missing answer(s) and re-check the captcha box at the bottom to submit. A copy of this form will be sent to you at the email address entered below, after you have completed the form submission. If you do not receive a copy in your email, please contact us as your submission was not properly processed.

Prescription or Medication Refill Request
Please allow 5-7 business days for prescription refills and 2 weeks notice for compounded medication requests. For urgent refills please contact the clinic directly. Thank you for providing all of the details we require to process your request below. We will contact you as soon as you medication(s) are ready for pick up.
Your Name*
First Last
Pet's Name*
First
Email*
Enter Email Confirm Email
Phone - Best Contact #
Medication Name and Strength (if applicable) i.e. Gabapentin 300mg or XCHT (Xiao Chai Hu Tang)*
Quantity - How much would you like?*
Please list the amount you are currently giving and the frequency of use. I.e. 1 tablet three times a day or 1/2 tsp twice daily*
Please provide an update on how your pet is currently doing. Are they improving, declining or staying the same on the medication?*
Photo of Medication(s)
You can upload pictures of the medication(s) you are requesting to refill to ensure you receive the correct one(s).
Drop files here or
Additional Supplements or Food Items
Do you need a refill of any supplements or food? If so, you can request it in the space below. Please make sure to include full product name and size requested.
Additional Medication Request
Would you like to order another medication?*
- Yes
- No
Medication Name and Strength (if applicable) i.e. Gabapentin 300mg or XCHT (Xiao Chai Hu Tang)*
Quantity - How much would you like?*
Please list the amount you are currently giving and the frequency of use. I.e. 1 tablet three times a day or 1/2 tsp twice daily*
Additional Medication or Product
Would you like to order another medication?*
- Yes
- No
Medication Name and Strength (if applicable) i.e. Gabapentin 300mg or XCHT (Xiao Chai Hu Tang)*
Quantity - How much would you like?*
Please list the amount you are currently giving and the frequency of use. I.e. 1 tablet three times a day or 1/2 tsp twice daily*
Comments
This field is for validation purposes and should be left unchanged.

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Prescription or Product Refill Request Form

Prescription or Medication Refill Request

Additional Medication Request

Additional Medication or Product