Pharmacy Refill Online Form
***Please allow 24-48 hours to complete your request. We will reach out when it is ready. ***
Location to Fill Prescription At
*
Please Select
West Loop
Streeterville
Owner's Name
*
First Name
Last Name
Preferred Phone Number
*
Preferred Email
*
Pet's Name
*
Medication Name
*
Strength (Ex: 25mg or 5mg/ml)
*
How much and how often is the medication given (Ex: 2 tablets every 12 hours)
*
Do you have additional prescriptions that need filled?
Yes
No
Is this for the same pet as listed above?
*
Yes
No
Pet Name
*
Medication Name
*
Strength (Ex: 25mg or 5mg/ml)
*
How much and how often is the medication given (Ex: 2 tablets every 12 hours)
*
Where does the prescription need to be filled?
*
Pick-up from WLVC
Fill my prescription and mail it to me (local and non-controlled substances only)
Alternate Pharamcy
** Please allow up to 10 business days for delivery as USPS is experiencing significant delays. **
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Name
*
Pharmacy Number
*
-
Area Code
Phone Number
How would you like to be contacted with updates regarding the prescription
*
Phone Call
Text
Email
Upload a photo of your Pet's Prescription (Please click upload after selecting the image)
Additional Comments:
Submit
Should be Empty: