Sara Moore

RVT, VTS (ophthalmology)

Prescription Refill Request

Owner Name

Patient Name

Email

Date Requested

Is the owner currently out of medication:

Yes No

**Medication refills may take up to 48 hours

Primary Service

Primary Doctor

Name of medication requested

Strength

Quantity

Refills

Instructions

Notes

Requested Pharmacy/Phone:

Would the owner like to speak to the Doctor or Technician?:

Yes No

Phone Number to return Call:

IndyVet does not accept patients for routine/general medical care