• New Patient (Animal) Information Form (Ver 1.1 10/13/23)

    We require this basic information to treat your pet.
  • Species*

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  • Pets BirthDate*
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  • Pet's Sex*
  • Does your pet have any DRUG or FOOD allergies*
  • Are you giving any other medications, prescription or over the counter to your pet?*
  • Does your pet have any of these chronic health conditions?*

  • Do wish "Child Resistant" lids on your containers

  • Lopez Island Pharmacy Patient Notification Options

    Use these options to tell us who is involved in your care, so that we may provide them with the information they need to assist you. We will act upon the information you provide on this form unless your inform us that it has changed. This form does not apply in the hospital setting
  • I would prefer to get Rx Pick Up Notifications via:
  • You can leave messages at my home or on my cell phone regarding my pet's health
  • You may E-Mail me a recap of my pet's appointment and care plan
  • You may speak to family members or friends regarding my pet's health care

  • The individuals listed below are involved in the ongoing care of my pet. Lopez Island Pharmacists and staff may provide them with limited information about my pet's condition and care as needed to assist me.

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  • Relationship
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  • Relationship
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  • Relationship

  • You will receive a call, email or text to the contact number you provided when the prescription is ready for pickup.

  • Other Information

    I am satisfied with the explanation regarding this form that I request and received
  • Todays Date*
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  • Relationship
  • Should be Empty: