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Prescription or Product Refill

Please complete this form so that we can organise your prescription or product refill. If you would like your product delivered, we will contact you to arrange payment. We routinely require 48 hours notice for refills. If you need medications more urgently, please call our reception on 6285-3196 so that we can assist you. Please note that we are required by law to see your pet regularly to dispense prescription medications. If your pet has not been seen in the last 6 months (or more recently if advised by your vet) we are happy to dispense a small amount of medication to allow you time to book a checkup.

client details

First name ^*

Last name ^*

Email ^*

Address

Phone

animal details

Animal Name ^*

Animal species

Select Dog Cat Bird Guinea Pig Reptile Rabbit Horse Other

pet medical history

Has your pet been seen by a veterinarian from this practice in the last 6 months?

Yes

No

Do you have any concerns with the health of your pet?

Yes

No

If yes, please describe any health concerns.

Has your pet recently shown any

Change in Appetite

Change in Thirst

Change in Activity/Comfort

Change in toileting habits

Vomiting

medication details

Please list all of the medications that your pet is currently on, including any supplements

Please select the product your require a refill for

Heartworm prevention

Flea or tick prevention

Worm prevention

Food

Non-Prescription Medication

Prescription Medication

Please list the names, strength and amount of the products required

Please list what dose and at what frequency you are currently administering the medication(s)

Delivery Options

Please deliver to the address listed above (please allow 7 days, our reception will call to arrange payment by phone)

I will collect my pet’s order (please allow 2 full days then simply drop in, we will call you only if a delay is expected)

By submitting this form, I acknowledge that I am the owner or agent representing the pet named above and that the information here is true and correct.

^*

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Full name

Today's date

AMENDMENT

Amendment Description *
Update estimate *
I, the undersigned, acknowledge that I have read and understood this amendment, which has been fully explained to me, and that it modifies the original consent form to which it is attached. I confirm that all information provided is accurate and that I consent to the changes outlined in this amendment. I understand that this amendment is part of the original consent form.

Signature

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SAVE

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