Prescription Auto-Refill Enrollment

Thank you for your interest in enrolling in the Prescription Auto-Refill Program! Please complete the form below. *Please note that your card will not be charged and your pet will not be enrolled until your pet's heartworm test is verified. We will contact you with any additional questions.**

First & Last Name*

Email Address*

Phone Number*

Mailing Street Address*

City & State*

Zip Code*

Pet's Name*

Species*

Pet's Weight*

One TIme Charge

I would like this to be a one-time charge only.

Name of Prevention*

Date Next Dose is Due

I would like to purchase my pet's prevention:*

Date & Location of Last Heartworm Test (dogs) or Annual Vet Visit (cats)*

How Did You Hear About Us?*

Credit Card Number

Expiration Date

Trifexis
Revolt (same as Revolution) for Dogs
Revolt (same as Revolution) for Cats
Simparica Trio
Heartgard
Advantage Multi for Dogs
Advantage Multi for Cats
Interceptor Plus for Dogs
Interceptor Chewable for Cats
Tri-Heart
Sentinel Spectrum
Bravecto (dogs only)
Bravecto Plus (cats only)
Nexgard
Cheristin
Credelio
Revolution

Prescription Auto-Refill Enrollment

PARP Enrollment Form