Veterinarians Submit RX Form

1. Pracitice Information

Practice Name*

Practice Phone Number*

Street Address*

Street Address 2 (Apt, STE, etc...)

City

State

Postal Code

Country

2. Prescribing Veterinarian

Full Name

License Number

3. Pet Parent Information

Pet Parent First Name*

Pet Parent Last Name*

Pet Parent Phone Number*

Pet Parent: Street Address*

Pet Parent: Street Address 2

Pet Parent: City

Pet Parent: State

Pet Parent: Country

4. Pet Information

Pet Name

Pet Date of Birth

Pet Species

Pet Gender

Pet Allergies

Pet Weight

5. Medication

Medication

Strength

Formula Form

Days Dispensed

Number of Refills

Additional Notes

I acknowledge that I have read and agree to the Privacy Policy.I acknowledge that I have read and agree to the Terms and Conditions.Selecting this checkbox serves as a legally valid signature for the submitted prescription using the information in Section 2.

SUBMISSION SENT

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