prescription refillplease complete the form belowCLIENT INFORMATION First Name (required) Last Name (required) Address (required) City (required) Zip Code (required) Email (required) Phone (required) PET INFORMATION Name (required) Breed (required) Color Age (required) Species CanineFelineOtherSex Male, IntactMale, NeuteredFemale, IntactFemale, SpayedMEDICATION(S) REQUESTED FOR REFILL Name Strength Dose Quantity requested I certify that my pet is currently taking the requested medication(s) and was previously advised to continue the medication(s) by a licensed veterinarianI have been counseled on the side effects of the medications listed above and release all liability from Folsom Ranch Veterinary Hospital and Urgent CareI understand that Folsom Ranch Veterinary Hospital requires 48 hours to process and fill prescriptions. If you are in urgent need of a medication and require the refill prior to 48 hours, please call us. An urgent prescription filing fee will apply.CONSENT I am over 18 years of age and am the authorized owner and-or guardian for the aforementioned patient. I authorize Folsom Ranch Veterinary Hospital and Urgent Care (FRVH) to perform treatment/procedure(s) on my pet(s) as recommended by FRVH's Veterinarians and employees. I was informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved. I confirm that by signing below, I understand the inheritable and sometimes unforeseen risks associated with veterinary care and release all liability, without exceptions, from Folsom Ranch Veterinary Hospital (FRVH) while treating my pet(s). I understand that payment is required for all services at the time they are rendered unless prior arrangements have been made with hospital management. I understand that deposits may be required prior to certain procedures. In the event that a refund is due and the original payment is a credit card, the refund will be posted against the original credit card. I also authorize FRVH to use pictures of my pet(s) for learning or marketing purposes. Consent will apply to all future pets added to this account unless and until I provide a written revocation of that consent.SIGN BELOW
