Prescription Refill Request

    Please complete the following form to request a prescription. Please note that requests may take up to 72 hours. A representative from BVNS will contact you to confirm receipt of your request.

    Contact Information

    Select a title

    Your Name

    Your Phone

    Your Email

    Patient’s Name

    Select a BVNS Location to Contact

    Select your Neurologist


    Prescription Request

    Name of Drug:

    Strength:

    Amount:

    Date Needed:

    How would you like to obtain your prescription?
    Pick-up at local BVNS
    Call In to local Pharmacy
             Pharmacy Name
            
             Pharmacy Phone
            

    Ship to your home
             Street Address
            
             City, State, Zip Code
            


    Please provide an accurate list of your pet's medications including the prescription strength and current dose.


    Please provide an update on your pet below

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    Atlanta, GA
    (678) 400-0042
    CALL
    Leesburg, VA
    (703) 669-2829
    CALL
    Richmond, VA
    (804) 716-4716
    CALL
    Rockville, MD
    (301) 637-4248
    CALL
    Springfield, VA
    (703) 451-3709
    CALL