Medication Refill Form START NOW 7 Medication Refill Form All fields marked with * are required and must be filled. Please enable JavaScript in your browser to complete this form.Please note: Some refills may require a visit prior to filling. If there has been a change to your pet’s medical status or your pet has not been seen in over 6 months, you may be required to set up an appointment prior to a prescription refill. VSES has a 24-hour policy on all medication refills. If your prescription needs to be picked up on the same day, an additional $10 processing fee will apply. Name *FirstLastPhone *Email *PET INFORMATIONPet's Name *Prescription Requested *Dosage (How are you currently giving this medication?)DoctorDr. Michael KochDr. MurrayDr. PalermoDr. HoffmanDr. St. GermaineDr. Seth KochDr. LedbetterDr. DeweyHow would you like to receive your prescription? *Pick up medicationPick up written prescriptionCall prescription into a PharmacyMail medication to my homeMail written prescription to my homeDeliver to MVA general practice veterinarianPlease note: A Customer Service Representative will contact you, requesting payment, prior to mailing/shipping. Shipping is an additional $10. Some prescriptions are unable to be mailed due to controlled substance laws.Mailing Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDesired pick up date and time *DateTimePlease State Which MVA Practice *Animal Junction Veterinary ClinicBayview Animal HospitalCanandaigua Veterinary HospitalCats and CrittersChili Animal CareCompanion Animal HospitalFairview Veterinary HospitalGreece Animal HospitalIrondequoit Animal HospitalPenfield Veterinary HospitalPerinton Veterinary HospitalPittsford Animal HospitalRochester Community Animal ClinicStone Ridge Veterinary HospitalSuburban Animal HospitalPharmacy Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePharmacy's Phone *If you would like to provide the doctor with an update on the patient, please do so below:Submit