Brookeside Veterinary Hospital Rx Request Form

Can't Find What You're Looking For?

If you can't find your Pet Prescription in our Online Pharmacy,
just fill out this Special Request Form below and submit it online.

All pet prescriptions must be authorized by the Veterinarian.
If the Veterinarian does not authorize your prescription,
you will be notified via E-mail with instructions to make an appointment for your pet.

PLEASE NOTE: OUR PRESCRIPTION SERVICE IS FOR PATIENTS OF
BROOKESIDE VETERINARY HOSPITAL ONLY.

For VetStore Refills,
please call the office at (734) 761-7523

Pet's Name

Your Name

Your Address

City

State

Zip

Telephone

Evenings

E-mail (Required) *

Name of Medication

Dosage (mg., etc.)

No. of tablets/capsules, etc.

Is this a refill?

Yes

Comments or Questions for the Veterinarian:

Charge to which credit card

Credit Card. No.

Expiration Date

CCV (3-digit number on back of card)

Name on Card

Billing Address

City

State

Zip

All prescription requests MUST be authorized by the Veterinarian.
If the Veterinarian does not authorize your prescription,
you will be notified via E-mail
with instructions to make an appointment for your pet.

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