Cumberland Animal Clinic

216 Greely Road
Cumberland, ME 04021

(207)829-5078

cumberlandanimal.com

                               Prescription Request   

In our ongoing effort to make your pet's health care as convenient and easy as possible, we provide the following form for you to submit a refill request of your pet's medication(s).  A technician and/or doctor will review your request and make a determination regarding approval. In the event we cannot fill your request, we will contact you directly to discuss why and available options. Please be sure to provide the best contact number where you can be reached in the event we need to speak with you directly.

We will notify you via email or phone when your pet's prescription is approved and ready. If you have requested to pickup at a pharmacy, please call the pharmacy to ensure they have your prescription ready. 

Please be advised: Providing quality health care requires that we only prescribe to active patients who have had a full physical exam within the last year. If it has been longer than a year since we've given your pet a nose to tail wellness exam, we will need to schedule an appointment. This would be true for any veterinarian, as it is required by both our medical ethics and the law. We apologize for any inconvenience and thank you for understanding. Your pet's health is our top priority.






Please submit the information below and we will review your request as soon as possible:

Prescription Request Form

Name
First Name
Last Name
Phone
Phone TypePhone Number
Patient #1 Name, Medication(s) & Quantity Requesting

Patient #2 Name, Medication(s) & Quantity Requesting

Patient #3 Name, Medication(s) & Quantity Requesting

Medication Administration
(Are you giving these medications as originally prescribed?)
Yes
No
As Needed
Prescription
(How would you like to receive your refill(s)?)
Pickup at Practice
Pickup at Pharmacy
Please Mail (postage fees are applicable)
Refill Notes / Additional Comments


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