Lennox Animal Hospital Rx Refill Request

PLEASE NOTE: THIS SERVICE IS
ONLY FOR CLIENTS OF
LENNOX ANIMAL HOSPITAL

Date

Your Name

Pet's Name

Street Address

City

Province

Postal Code

Phone

Cell Phone

E-mail

Name of Medication

Dosage (mg. etc.)

No. of Tablets, Capsules, etc.

Is this a refill?

Yes

Comments or questions for the veterinarian

Name on Card

Credit Card Type

Credit Card Number

Expiration Date (mm/yy)

3-digit Security No.

NOTE: Clients must allow 24 hours for their prescriptions to be filled. All prescriptions are subject to availability. Most prescription requests are filled and shipped within 24 hours. You will receive an e-mail notifying you of the amount of the charge, or if the prescription cannot be filled we will contact you. If you wish to pick up your prescription and pay for it upon pickup, please tell us in the Comments section above.

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