Prescription Refill/ Food and Retail Order Request Type of Request: *Type of Request:Food Item OrderPrescription RefillFirst Name *Last NameEmail Address *Phone *Location *Grande PointeThompsonAnimal Name: *Medication Name: *What is the concentration of this medication?Quantity of this medication requested * *How often is your animal getting this medication? *How much of this medication is your animal getting per dose? *How is your animal doing on this medication? *Additional Notes:Photo of medication or PrescriptionChoose FileNo file chosenDelete uploaded fileFood/Supplement/Retail Item OrderName of food/supplement/retail item *If you are unsure how to spell it, please spell how it sounds or include a photo of your current food, supplement or retail item below and indicate here that you have. Please include the brand and name of products whenever possible. If this is a food item, please include type (ie. pate, stew, kibble, etc) and flavour.Size of food, supplement or retail item *For food items, please include the weight. For retail items, please include weight or quantity in a package if applicable. If item is one-size, such as a toothbrush, please enter 1Quantity of above-mentioned size * *How would you like to be contacted when your order is ready?Text cell number on filePhone call number on fileEmail address on fileNumber/email not on fileNotesPhoto of Product *Choose FileNo file chosenDelete uploaded fileHow would you like to be contacted when your order is ready? *Text cell number on filePhone call number on fileEmail address on fileOther Email or Phone NumberEmail/Phone *Send Message
