(PLEASE ALLOW 24 HOURS FOR PROCESSING)
Date
Name
Pet's Name
Home Phone
Work Phone
Prescription to be refilled
Quantity
Instructions for use
This prescription is to be refilled in the following manner Select one of the following Pick up at clinic (Please allow 24 hours) Call in to pharmacy (Please allow 24 hours) Place through online pharmacy(Please allow 24 hours)
If this prescription is to be called into a pharmacy, please provide:
Rx#
Pharmacy Phone Number Select a Pharmacy Giant-Kingstowne 703-313-8092 Rite Aid-Manchester Lakes 703-922-4604 Wal-Mart-Kingstowne 703-924-8805 Alexandria Medical Arts 703-549-4350 CVS-Franconia 703-644-6312 Giant-Hayfield 703-922-6620 Giant-Huntsman Square 703-866-2336 Giant-Van Dorn 703-370-0122 Giant-Cardinal Forest 703-569-6866 Giant-Springfield Plaza 703-569-5401 Rite Aid-Rose Hill 703-971-2200 Safeway-Rose Hill 703-313-8802 Safeway-South Van Dorn 703-823-2641
If your pharmacy telephone number was not listed, please enter it here
Special Instructions
2nd Prescription
2nd Rx#
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