Pet Medicine Refill Request Form

for Clinics Hosted by the Humane Society of Saline County

You must pay CASH when you pick up refill, remember NO checks or debit/credit cards.
We will email you when your order is ready for pick up.
Check all entries for accuracy, then press the "Submit" button ONLY ONCE.
If you do not receive a confirmation email after you hit Submit, please re-submit your request.

First Name: *
Last Name: *
Street Address: *
City: *
State: *	AR AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code: *
Cell Phone Number: *
Home Phone Number: Please use the following format 248-555-1212
Work Phone Number:
Email Address: * Please enter correctly as this is the main way we will contact you
Pet Name (One pet per form): *
Pet Weight: *
Date you would like to pick up your refill: *
Flea/Tick Products
Dog - Nexgard (30 day prevention) $15 a pill	Select weight 4 - 10 lbs 10 - 24 lbs 24 - 60 lbs 60 - 120lbs
How many Nexgard pills? *
Dog - Bravecto (3 month prevention) $45 a pill	Select weight 4 - 9.9 lbs 9.9 - 22 lbs 22 - 44 lbs 44 - 88 lbs 88 - 123 lbs
How many Bravecto pills? *
Cat - Catego (30 day prevention) $12 a drop	Select weight 1.5 lbs and up
How many Catego Drops? *
Dog Heartworm Prevention 6 Month Supply Refill (Dog must be Heartworm tested HERE once a year)
Iverhart Max	Select weight 0 - 25 lbs ($20 for 6 month supply) 25 - 50 lbs ($25 for 6 month supply) 50 - 100 lbs ($30 for 6 month supply)
How many 6 month supplies? *
Notes: