Rx Refill Request

Cloverleaf Animal Clinic

749 N. White Station
Memphis, TN 38122

(901)682-5681

cloverleafac.com

Decorative Bone Divider

**By law, we are unable to refill prescriptions without a valid veterinarian/client/patient relationship.

This means one of our veterinarians must have examined your pet within the past 12 months in order for us to refill any prescription.

In some cases, we may require that additional testing be required for a refill**

Please allow 24 to 48 hours for prescription requests to be processed. A staff member will contact you if more information is needed.

Name (required)

First Name (required)	Last Name (required)

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone
Phone Type	Phone Number

E-Mail Address (required) :

Pet's Name (required)

Type of Pet (required)

Canine
Feline
Exotic

Have we seen your pet within the past year? (required)

Yes
No

What medication(s) would you like refilled? (required)

Additional questions/comments

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