Prescription Refill Request

    Please complete the following form to request a prescription in its entirety. 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 (required)

    Select your Neurologist

    Prescription Request

    Name of Drug*:

    Strength (i.e. 100mg)*:

    Amount/Dose (i.e. 2, every 2 hours)*:

    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


    Enter characters from above

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