UWVC Client Request to Fill Prescription at Outside Pharmacy

UWVC Client Request to Fill Prescription at Outside Pharmacy

Please use this form to request a prescription food or medication refill with an outside pharmacy or online vendor.

Please allow 2-4 business days for your request to be fulfilled by UWVC personnel. If you have an urgent refill need, please call 608-263-7600 and connect with the prescribing service directly.

Your Full Name:*

Please include both the first and last name affiliated with your UWVC client account.

How would you prefer to be contacted, if there are questions regarding your request?*

Select

Your Phone Number:*

Please list a phone number we can contact you at, in case any questions arise with your request.

We kindly ask that you please respond to any follow-up on your request within 24 hours.

Your Email Address:*

Please list an email address we can contact you at, in case any questions arise with your request.

We kindly ask that you please respond to any follow-up on your request within 24 hours.

This request is for (PATIENT NAME):*

Please enter the UWVC patient's name that this request is for.

Please note that we cannot submit refills for non-UWVC patients or patients who have not been seen by the UWVC prescribing service within the past 12 months.

The following service has prescribed this item for my patient:*

Please select the prescribing service from the list below. This is the service your request will be routed to.

Select

UWVC Client Account Number or Patient's Medical Record Number:*

Would you like to submit a request for prescription food or a medication refill?*

Select or enter value

Prescription Name:*

Please be as complete and descriptive as possible.

Name of Food:*

Include brand, formula, and flavor preferences. Ex. Purina Savory Selects EN Gastroenteric with Lamb in Gravy Canine Formula, Canned

Size / Weight Preference for Bag Food:

Quantity of Medication / Food Needed:*

Ex. 60 tablets, 3 months' supply, etc.

Date Needed By:*

Name of Pharmacy or Website You Would Like Prescription Sent to:*

Please include complete information of where you would like this prescription sent, ex. Costco, Hoey Apothecary, https://www.chewy.com/.

Pharmacy Location:

If this is NOT an online pharmacy, please include the pharmacy's physical/street address, to ensure we send the prescription to the correct location.

Pharmacy Contact Information:*

Please list the phone number or email address of the outside pharmacy where UWVC is submitting this prescription for you.

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