Prescription Refill Request Form Prescription Refill Policy Highlights If you have multiple pets, please submit a separate form for each pet Refills will be processed during our office hours, Monday through Wednesday Refill requests from our in clinic pharmacy may take up to 5 business days to process Refills needed within 72 hours of request will incur an additional $25 fee (See Below) In clinic pickup (by appointment) or free home shipment of medications available Paper prescriptions will be provided for clients wanting to use an external pharmacy (i.e. Walgreens, Fred Meyer, Chewy, etc). These may be picked up at our facility or mailed. Please view the full policy here Client and Pet InformationFirst Name*Last Name*Pets Name*PLEASE NOTE - YOU SHOULD SUBMIT A REQUEST FOR A SINGLE PET AT A TIME. WE WILL NOT PROCESS MULTIPLE PETS IN THE SAME PRESCRIPTION FORM ENTRY.Prescription Information (ONE PET PER SUBMISSION)Drug or Supplement Name*Strength of Dose*Dosage Per Day*Daily Doses Left*UntitledQuantity Requested (Required)Thirty (30) Day Supply (1 mo)Ninety (90) Day Supply (3 mo)Please note that you can request up to the maximum amount allowable until just after your next Behavior Progress Evaluation (BPE). For example: if your next BPE is due in 2 months, you may request up to 3 months of meds.brief behavioral update*Order InformationDo You Approve a Rush Charge? (Choose One)* Approve Rush Charge Rush Not Needed It is important to not stop behavioral medications abruptly. If you need a medication to be refilled quickly due to your pet running out within 72 hours, this will incur a $25 Rush Charge. This is because our doctors and staff will need to be pulled from other duties to fulfill this request quickly. The charge will be made against the card we have on file for your account.Do You Approve Using Your Card on File?* Please Charge My Card On File Please Call Me To Get New Card Info Please let us know how you want us to charge thisHow would you like to get your medications? Synergy In-House Pharmacy (Mailed to Me) Synergy In-House Pharmacy (Picked up at Synergy) Paper Prescription (Mailed to Me) Paper Prescription (Picked up at Synergy) Contact InformationEmail* Phone*Address*Additional RequestsThis field is hidden when viewing the formShort Notice Charge Agreement My pet needs medication refilled within 72 hours, and I agree to the $25 charge as described below It is important to not stop behavioral medications abruptly. If you need a medication to be refilled quickly due to your pet running out within 72 hours, this will incur a $25 Rush Charge. This is because our doctors and staff will need to be pulled from other duties to fulfill this request quickly. The charge will be made against the card we have on file for your account.Please review the following:Our veterinary staff will review your prescription request during our standard business hours, Sunday at 9am through Thursday at 3pm. We recommend that you make your prescription request at least a week before you run out. If there is some urgency to your request, please call us directly or email us to let us know. There is an additional charge for "Rush" requests.By submitting this form you are agreeing to our terms and conditions outlined above.EmailThis field is for validation purposes and should be left unchanged. Δ SERVICES VET BEHAVIOR HEALTH ASSESSMENT VET CARE RECOVERY PROGRAM BITE-SIZED BEHAVIOR CONSULTS Dog Training & Behavior Modification ABOUT US OUR TEAM JOIN US! CLASSES VIDEOS ON DEMAND SUCCESS STORIES OTHER ITEMS ONLINE PAYMENT PAGE FAQs RESOURCES OUR BLOG FOR PET OWNERS CONTACT US