Tri State Medical Group

Pharmacy

TRI-STATES VETERINARY MEDICAL GROUP
33 JERSEY AVENUE
PORT JERVIS, NEW YORK 12771
TELEPHONE 845-856-1914
FAX 845-856-1918
E-MAIL TRISTATEVET@GMAIL.COM

PRESCRIPTION REFILL REQUEST


Client Name:
Address:
Telephone: (Day Time)
E-mail:
Pet Name:
Breed:		Age:
Medication:		Dosage:
Directions:
Quantity:
PLEASE ALLOW 2 DAYS FOR REFILL. IF WE CAN NOT FILL THIS PRESCRIPTION WE WILL CONTACT YOUR DAYTIME TELEPHONE NUMBER

SEND