Third Party Pharmacy Rx Request

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

Rx: Prescription Request Form for Outside Pharmacies

NEW & UPDATED PHARMACY POLICIES

medicine icon In order to provide the best patient care possible, streamline refills and ensure only quality medication & products are delivered to patients, Dr. Brown is exclusively working with her trusted partner MYVETSTOREONLINE via Midwest Veterinary Supply and will no longer be authorizing prescriptions from outside third party pharmacies, online or local.

Clients can access MYVETSTOREONLINE directly from this site and create a pet account to receive instant savings, free shipping on qualifying orders and competitive pricing, all while supporting Dr. Brown as a local small business vendor.

COMPLIMENTARY WRITTEN PRESCRIPTIONS may be requested for owners that wish to continue to utilize outside third party pharmacies to submit themselves directly to the local or online pharmacy of their choice.

Written prescriptions are available during in person appointments or via local pick up at Soul Puppy (downtown Mesa office) or by mail. Please email brownvethc@gmail.com to request a written prescription.

medicine icon Please submit this OUTSIDE PHARMACY REFILL REQUEST FORM only if you wish for Dr. Brown or remote staff to phone in your pets prescription to an outside third party pharmacy

There is a $22 fee per call for Dr. Brown/remote staff time

Note: the above fee is waived if a prescription medication is not available in MYVETSTOREONLINE such as controlled or highly monitored drugs, if the medication needs to compounded at a compounding pharmacy because an FDA approved product is not available for the patients weight or if directly waived per Dr. Brown

THANK YOU FOR YOUR UNDERSTANDING AND SUPPORT!

Note: For JIng Tang Herbal Refills please email brownvethc@gmail.com. Standard Process orders can now be obtained directly via Patient Direct.

IMPORTANT:

Please allow up to 48-72 hours for refill 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

Please confirm directly with your third party pharmacy of choice prior to submitting this form that the medication being requested is carried by your chosen pharmacy. Please contact your third party pharmacy of choice directly for processing updates

Please schedule an appointment if it has been MORE THAN 12 MONTHS since your pets last exam

THANK YOU FOR SUPPORTING OUR SMALL BUSINESS ONLINE PHARMACY

Outside Pharmacy Refill 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)

Type of Preferred Pharmacy (please choose one only)

Local Pharmacy (Important: owner must confirm directly with local pharmacy of choice that medication is available at pharmacy prior to submitting this form)
Online Pharmacy
Other

Name of preferred pharmacy

Phone number of preferred 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. Brown

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