Form - Prescription Refills

Client ID Number (if known)

Name (required)
First Name (required)
Last Name (required)
Pet's Name (required)

Name of Drug & Strength (mg) (required)

Quantity (required)

E-Mail Address (for confirmation of your request) :
Daytime Phone Number (required)

I would like to:
Option I - Have my prescription mailed
Option II - Picked up at Brittmoore
Option I - Please Type Your Mailing Address Here

There is a $14.50 delivery charge. All prescriptions are mailed by Federal Express Ground.
Option II - Requested Time Of Pick-up (required)
Before Noon
After Noon
Today
Tomorrow
Comments

Federal Law Prohibits The Dispensing Of Certain Medications Without Examination Or Prescription.

The verification code below ensures the form is not submitted by a computer
Verification Code :
Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.