Central Park Veterinary Clinic

252 Route 108
Somersworth, NH 03878

(603)742-1203

www.centralparkvet.net

Medication Refill Request

Please complete the form below to request a refill of your pet's medication.

In our ongoing effort to make your pet's health care as convenient and easy as possible, you can now request a refill for your pet's prescription by submitting the following form. Please be sure to fill in all the requested information. The prescription refill must be approved by a doctor. It can take up to 2 business days to process a request and fill the prescription.

We will notify you via email, text or phone call when your pet's prescription is approved and ready to be picked up. If you would prefer to pick up a written prescription, please mention this in the additional information area.

Online medication orders: If you will be ordering your pet's medication online, please consider using our online store (click the online order button at the top of this page). Wherever you order online, you can place your order (make sure to list Central Park Veterinary Clinic as your veterinarian) and most online pharmacies will send us a request for approval. You do not need to complete this form to request an online refill.

Medication Refill Request Form

Note:
Medication Refill Requests are processed within 48 hours, or 2 business days. Compounded medications are special order items and will take longer than 2 days in most cases. Prescription pet foods that require special order can take up to 7-10 days to arrive. If you need your pet's medication sooner than that, please call our office at (603)742-1203

Pet Owner's Name (the name listed on the pet's medical record) *(required)*

First Name (required)	Last Name (required)

Is the person requesting this refill the primary owner on the pet's account? (If no, please give us your name. Please note that only the owner or other authorized agents on the account can request medication refills or consent to treatment for a pet.) (required)

Pet Owner's Address
Street Address

City ,	State / Province	Zip / Postal Code

E-Mail Address of Primary Pet Owner on Account (required) :

Phone Number of Primary Pet Owner on Account (required)
Phone Type	Phone Number (required)

Pet's Name (required)

Sex (required)

Male
Female

Age: Years, Months

Medication Requested (required)

Medication Dose and Frequency (Please list the dose you are actually giving your pet if that differs from the label instructions on the prescription) (required)

Have we seen your pet within the last year for the problem requiring treatment with this medication? (required)

Yes
No

How is your pet feeling? Do you have any questions or concerns at this time? (required)

My pet is doing well
My pet is doing ok, about the same as last visit
My pet is not doing well
I am very concerned about my pet at this time

Additional Comments / Questions

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(603) 742-1203

Central Park Veterinary Clinic

Medication Refill Request

Medication Refill Request Form