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Mayfair Animal Hospital - Prescription Request
Please complete this form to request a prescription refill. Note that all refills must be approved by a doctor. Please allow 1 full business day for your medication to be ready for pick-up.
Client/Patient Information
Name
*
First
Last
Pet's Name
*
Email
*
Phone Number
*
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Prescription Information
Medication name and dosage (per tablet/capsule/mL):
*
E.g. Metacam 1.5mg/mL, Rimadyl 25mg
Quantity requested:
*
Amount per dose:
*
E.g. 1/2 tablet, 2 capsules, 4 mL
Frequency of dosing:
*
Select One
Once daily (every 24 hours)
Twice daily (every 12 hours)
Three times daily (every 8 hours)
Four times daily (every 6 hours)
Every other day
Only as needed
Not listed
Do Not Fill This Out
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