Alta Vista Veterinary Hospital

****Professional Fees are to be paid at the time services are rendered***
If services are not paid in full at the time of services, a 1.5% finance charge will be issued on the balance until paid in full. Should the services of a collections agency be necessary, a collection fee equaling 40% of the outstanding balance be added to the account.

Prescription Refill Request
Your Name:	(required)
Pet's Name:	(required)
Pet Type:	(required)
Name of Medication:	(required)
Medication Dose:
Medication Quantity Desired:
Email Address:
Your Phone:	(required)
Alternate Phone:
You may enter any additional instructions or comments you might have in this area.