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Prescription Refill Request – Neurology & Neurosurgery
All prescription refills must be approved by your pet’s neurologist.
Prescriptions cannot be refilled for patients that have not been examined by one of our doctors within the past year.
If your pet’s medical condition has changed, or if he/she is experiencing problems or suspected side effects, please call 713-341-9520 to discuss your pet's medical condition.
When possible we will try to accommodate larger prescriptions, however, certain controlled substances will only be prescribed in 30 day or less quantities.
The maximum quantity for a single refill when allowed is 90 days.
Please allow a minimum of 24 hours for refills to be processed. If you require medication in less than 24 hours please call 713-341-9520. Additional fees to fill urgent prescription requests may apply.
If more than two prescription refills are requested, please fill out a separate form.
Date
MM slash DD slash YYYY
Name
*
First
Last
Phone
Email
Preferred Contact Method
*
Phone
Email
Pet's Name
Neurologist’s Name
Dr. Longshore
Dr. Giovanella
Dr. Vasquez
Prescription 1
Medication Name
*
List the medication name as found on the prescription label.
Medication Strength (from the previous prescription)
*
List the medication strength in mg
Medication Directions (from the previous prescription)
*
Has your pet’s medication dosage changed since the last prescription?
*
Yes
No
Quantity Desired
*
30 Days
60 Days
90 Days
Prescription 2
Medication Name
*
List the medication name as found on the prescription label.
Medication Strength (from the previous prescription)
*
List the medication strength in mg
Medication Directions (from the previous prescription)
*
Has your pet’s medication dosage changed since the last prescription?
*
Yes
No
Quantity Desired
*
30 Days
60 Days
90 Days
Prescription 3
Medication Name
*
List the medication name as found on the prescription label.
Medication Strength (from the previous prescription)
*
List the medication strength in mg
Medication Directions (from the previous prescription)
*
Has your pet’s medication dosage changed since the last prescription?
*
Yes
No
Quantity Desired
*
30 Days
60 Days
90 Days
Pick-up & Additional Information
Where would you like to pick up the medication?
*
GCVNN
Other Pharmacy
Your Pharmacy’s Name
Your Pharmacy's Phone
Pet Update
Please provide a brief update on how your pet is doing.
Questions & Comments
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
