Rx Refill

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

RX: Prescription Request Form

In an ongoing effort to make your pet's health care as convenient as possible, please submit a REFILL REQUEST FORM for your pet's prescription medication and diets, Chinese herbs, food or supplements. Note: Standard Process orders can now be obtained directly via Patient Direct.

This form will be emailed directly to Dr. Brown for approval and processing.
Dr. Browns ONLINE ASSISTANT, DEB, may email questions or updates to you from the following emails
- brownvethc@gmail.com
- staffbrownvet@gmail.com.
  - this email is for internal use only
As Dr. Brown is typically with a patient or traveling for a housecall, THIS FORM EXPEDITES YOUR REFILL REQUEST.
- Please do not email refill requests (no text or social media messages please).

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
For OUTSIDE PHARMACIES, please confirm directly with your pharmacy of choice prior to submitting this form that the medication being requested is carried by your chosen pharmacy. Please contact your pharmacy of choice directly for processing updates i.e Chewy, Walgreens, Costco, etc.
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

Refill Request Form

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, Herbal, Supplement, Diet/Food, 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)

Dr. Browns Small Business Online Pharmacy with convenient home delivery via Jatrx by Midwest Veterinary Supply
Standard Process Whole Food Supplement Refill Home Delivery
Chinese Herbal Medicine Home Delivery Refill via Jing Tang
Local Pharmacy (Important: owner must confirm directly with local pharmacy of choice that medication is available at pharmacy prior to submitting this form)
Other Online Pharmacy
Other

Standard Process patients can now utilize Patient Direct

Yes, please send link to create my own Patient Direct Account
No, please continue to send SP as previously done with additional drop ship fee

Name of preferred pharmacy

Phone number of preferred pharmacy

Cross streets and city of preferred pharmacy if applicable

Prescription number or order number

If using an outside pharmacy, please click below if you would like to receive a price matching quote for Dr. Browns small business online pharmacy

Yes
No
Not Applicable

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