Cottner Creek Pet Clinic Prescription Refill Form

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.

We will notify you via email or phone when your pet's prescription is approved and ready to be picked up. We will also inform you of the total cost of the prescription, and will request a credit card number by phone at that time. If you would prefer to have the prescription mailed to you, please mention this information in the additional information area.
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Daytime Phone*
Evening Phone*
Pet's Name*
Sex*
- Male
- Female
Age: Years, Months*
Have we seen your pet within the last year?
- Yes
- No
Medication Requested*
Additional Comments / Questions