Cheat Lake Animal Hospital

Medication Refill Request Form

 

All medication requests will be reviewed by a veterinarian during our normal business hours.  We will contact you to confirm the request as soon as possible.  Please remember to submit your request at least a few days prior to the end of your pet's medication and generally allow 24 hours for a response.  If a response is not received within your required time period, please call us directly at (304) 594-1124. 

Please be aware that the medication requested can NOT be filled until a veterinarian has approved it. Many medications require that the pet have regular blood work screens or check-ups, so this may be required prior to refilling the medication.

All patients must have a medical relationship with one of our veterinarians.  It is unlawful to dispense medication to a pet whom we have not examined within the past year.

Please fill out all of the required information below, one form per pet.

Client Information:

*First Name
*Last Name
*Home Phone
*Work Phone
*E-mail

Pet Information:

*Name
Breed    
Age    

 

Medication Information:

First Medication:

*Name of Medication  
Other:    
*Strength of Medication
*Quantity Needed

Second Medication:

*Name of Medication  
Other:    
*Strength of Medication
*Quantity Needed

Third Medication:

*Name of Medication  
Other:    
*Strength of Medication
*Quantity Needed

 

*I would like to pick up these medications on:

Date

Morning   Afternoon    Evening
*How would you like for us to contact you regarding your refill request:  

E-Mail   Home Phone   Work Phone

Comments/Additional Information: