Medication Request Form

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Medication Request Form

Please fill out this form as completely and accurately as possible so we can fill your medication request.

What is your FIRST and LAST NAME? *

First

Last

What is your PET'S NAME?

What is your phone number?

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Medication name

How many / much would you like?

How much do you have left?

Any vomiting/diarrhea/dark stools?

What other medications/supplements is your pet on, and what dose?

When would you like to pick up, or which pharmacy to send to if we script out?

Medication strength

How much and how often are you giving this medication?

How is your pet doing?

Any changes in thirst/urination/appetite?

Any concerns with your pet?

What is your email address (to contact you when the medication is ready for pick up)? *

If this request is for Apoquel please answer these additional 2 questions. If this is not for Apoquel, please skip to the end.

Is there any yeast odor or other odor from your dog?

Are there any red spots, irritations or rashes present on your dogs skin? If yes, please describe.

Please allow 24 working hours for most prescriptions, 72 hours if we need to special order your pet's medication in for you.

Thank you,
Dr. Lynn Lam, Dr. Tom Oster, Dr. Christina Parker and the Whitehills Animal Hospital Team

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Medication Request Form

Medication Request Form

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