Prescription Request Form – Veterinary Dermatology Center

Client Name*

Pet's Name*

Phone Number*

Email (optional)

Medication Requested*

Quantity Requested*

Is this a refill or a new prescription?*

Refill
New Prescription

Type of Prescription

Regular Medication 🕒 (Please allow 24–48 business hours to process)
Allergy Serum (⚠️ Please allow 7–10 business days to process)

Where would you like the prescription sent?*

Pharmacy Name

Shipping Address

Shipping Fees: • Allergy Serums – $60 (Overnight FedEx) • Regular Medications – $18 Payment Information: You will receive a text or email with a payment link before shipment. Once payment is received, we will email you a receipt along with your tracking number and proceed with shipping.

Date of Last Appontment (if known)*

Any changes in your pet's condition since last visit?*

Yes
No

If yes, please explain