Refill Request Form - Animal Behavior Clinic of New Jersey

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***Doctors cannot authorize prescriptions for patients who have not seen the doctor in 12 months or more.***

In some cases, pets are asked to recheck with the doctor every 6 months. If you are unclear if your pet needs to schedule a recheck with the doctor before the doctor can authorize a refill for your pet's medication, please call (201) 503-7531 or email us at englewood@animalbehaviorclinicnj.com

Full Name *

Email *

Phone *

Patient's Name *

Medication

Please check which medication(s) you need refilled *

Acepromazine 10 mg tablets

Acepromazine 25 mg tablets

Adaptil collar Sm-Med

Adaptil collar Med-Large

Alprazolam 0.25 mg tablets

Alprazolam 0.5 mg tablets

Alprazolam 1.0 mg tablets

Alprazolam 2.0 mg tablets

Anxitane Small

Anxitane M&L

Buspirone 5 mg tablets

Buspirone 15 mg tablets

Buspirone 30 mg tablets

Calming Care Probiotic

Clonidine 0.1 mg tablets

Clonidine 0.2 mg tablets

Clonidine 0.3 mg tablets

Clonazepam 0.5 mg tablets

Clonazepam 1.0 mg tablets

Clonazepam 2.0 mg tablets

Diazepam 2 mg tablets

Diazepam 5 mg tablets

Diazepam 10 mg tablets

Escitalopram 5 mg tablets

Escitalopram 10 mg tablets

Escitalopram 25 mg tablets

Fluoxetine 10 mg tablets

Fluoxetine 20 mg tablets

Fluoxetine 40 mg tablets

Fluoxetine 10 mg capsules

Fluoxetine 20 mg capsules

Fluoxetine 40 mg capsules

Gabapentin 25 mg tiny tabs

Gabapentin 100 mg capsules

Gabapentin 300 mg capsules

Gabapentin 600 mg tablets

Lorazepam 0.5 mg tabs

Lorazepam 1.0 mg tabs

Lorazepam 2.0 mg tabs

Paroxetine 10 mg tablets

Paroxetine 20 mg tablets

Paroxetine 40 mg tablets

Reconcile 8 mg tablets

Reconcile 16 mg tablets

Reconcile 32 mg tablets

Reconcile 64 mg tablets

Sertraline 25 mg tablets

Sertraline 50 mg tablets

Sertraline 100 mg tablets

Sileo

Solliquin Small-Med

Solliquin Med-Large

Trazodone 50 mg tablets

Trazodone 100 mg tablets

Trazodone 150 mg tablets

Venlafaxine 25 mg tablets

Venlafaxine 75 mg tablets

Venlafaxine 100 mg tablets

Zylkene 75 mg capsules

Zylkene 225 mg capsules

Zylkene 450 mg capsules

Otros:

Obligatoria

Please let us know how frequently you give each of the medications you checked (e.g once a day, twice a day, prior to stressful event etc..) *

Please let us know how many pills/capsules you give of each medication *

How do you need the prescription processed? *

IMPORTANT: We can't call it into national chains (e.g., CVS, Walgreens, Rite Aid, etc.)

Entered into the online pharmacy (Covetrus)

Entered into Chewy Account

Entered into Mix Labs Pharmacy

Pick the medication(s) up at the clinic

Written script mailed to you

Call it into your local private pharmacy (WE CAN'T CALL IT INTO NATIONAL CHAINS)

If you need the prescription called into a pharmacy, please provide the phone number

Please note - it takes 72 hours for us to process refills. If you need a refill called in sooner than 72 hours for any reason, there will be a $25.00 emergency fee. If you need us to do this and authorize us to charge your card, please check this box

PLEASE NOTE: the clinic is closed on weekends and major holidays

Emergency Refill

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