Third Party Pharmacy Rx Request

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

Outside Third Party Pharmacy Prescription Request Form

medicine icon OUTSIDE THIRD PARTY PHARMACY

Please submit this required third party pharmacy request form only if you decline a complimentary written prescription to use directly via the pharmacy of your choice and wish for Dr. Brown or remote staff to phone in your pets new or refill prescription directly to an outside third party pharmacy

There is a $22 fee per call for the time that is needed for Dr. Brown & remote staff to communicate directly with outside third party pharmacies

COMPLIMENTARY WRITTEN PRESCRIPTIONS medicine icon MYVETSTOREONLINE

PROCESSING INFO

Please allow up to 48-72 business hours for approval and processing

Please request one medication per form to avoid errors

All patients must have an ACTIVE CLIENT PATIENT RELATIONSHIP (current exam by Dr. Brown within 12 months) BY LAW for refills

medicine icon IMPORTANT

Please confirm directly with the third party pharmacy of your choice PRIOR TO SUBMTTING THIS FORM that the medication being requested is in fact carried by your chosen pharmacy

Please contact your third party pharmacy of choice directly for processing updates

Outside Pharmacy Request

Name

First Name	Last Name

Address
Street Address

City ,	State / Province	Zip / Postal Code

Email address

Daytime Phone
Phone Type	Phone Number

Evening Phone
Phone Type	Phone Number

Pet's Name

Sex

Male
Female

Age: Years, Months

Approximate weight

Has your pet been examined by Dr. Brown within the past 12 months?

Yes
No

Name of Medication Requested. ONE REQUEST PER FORM PLEASE

Strength (Ex. 100mg)

Dosage: Number of pills/capsules/chews, route of administration and frequency of dosing (Ex. 1 tab by mouth twice daily)

Name of third party pharmacy

Phone number of pharmacy

Cross streets and city of preferred pharmacy if applicable

Prescription number or order number

Fee payment ($22 fee per outside pharmacy call) Note: Owners may request a complimentary written Rx to submit directly or utilize MYVETSTOREONLINE (required)

Zelle via 480-494-6034 or brownvethc@gmail.com
Venmo via @brownvethousecalls
Paypal via drbrown@brownvetservices.com
Fee waived per Dr. Brownces.com
Please send me an invoice

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