Prescription Refill Request Form

Prescription Refill Request

Existing clients may use this form to request prescription refills. Pending approval by a doctor, your pet's prescription will be ready on the next business day after 12 noon. If you need your medication sooner or request special mail delivery please indicate below in the comments section and one of our staff members will contact you for further details. Thank you!

URL
This field is for validation purposes and should be left unchanged.
Name*
First Last
Email*
Phone*
Pet Owner Date of Birth*
Required for controlled substance Rx
Pet Name*
Medication #1
Strength
Quantity
Please indicate how often you are giving this medication and in which eye
Medication #2
Strength
Quantity
Please indicate how often you are giving this medication and in which eye
Medication #3
Strength
Quantity
Please indicate how often you are giving this medication and in which eye
At which location was your pet most recently seen?*
- Animal Eye Care (Fremont)
- Animal Eye Care (Pleasanton)
Fulfillment Preference
A written prescription cannot be provided for the following medications: An-Vision (pickup only), Cefazolin (pickup only), Cidofovir, Cyclosporine, Demecarium Bromide, EDTA, Methazolamide, Plasma (pickup only), Tacrolimus. These must be either called into a compounding pharmacy or picked up at Animal Eye Care (Pleasanton). Please indicate below accordingly.
Preference for medications is to:*
- Mail to My Address
- Hold for Pickup
- Pick Up A Written Prescription
- Have a Written Prescription Mailed to My Address
- Call Into a Compounding Pharmacy
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please choose the Refill location:
- Animal Eye Care (Fremont)
- Animal Eye Care (Pleasanton)
Comments

Prescription Refill Request

Fulfillment Preference

Your Pet’s Vision is Our Top Priority!