Third Party Pharmacy Rx Request

Brown Veterinary Housecalls

Mesa, AZ 85205


Brown Vet Triple Logo

 Outside Third Party Pharmacy Prescription Request Form


 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

 Note: If your pet is under the care of a specialist or full service brick and mortar clinic for services not provided by Dr. Brown and has been prescribed medication by doctors at said facilities, all refill requests for medications not prescribed by Dr. Brown must be directed back to the prescribing doctor at said facilities. If the patient will no longer be seeking care at said facilities but contacts Dr. Brown to fill said medications, then either an updated exam by Dr. Brown or fee based TeLeVET Time to evaluate records/diagnositcs/labwork from other facilities will be required and determined on a case by case basis


medicine iconPROCESSING 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 iconIMPORTANT

 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

First Name
Last Name
Street Address
State / Province
Zip / Postal Code
Email address

Daytime Phone
Phone TypePhone Number
Evening Phone
Phone TypePhone Number
Pet's Name



Age: Years, Months

Approximate weight

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


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
Venmo via @brownvethousecalls
Paypal via
Fee waived per Dr.
Please send me an invoice

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