Controlled Medication Form: This Section to be Completed By Ghent and Granby Vet Employee
Individual Picking up Meds
*
First Name
Last Name
Address of Individual Picking up Meds
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number of Individual Picking up Meds
*
-
Area Code
Phone Number
Birthdate of Individual Picking Up Meds
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-
Month
-
Day
Year
Pet's Name
*
Account Number
*
Please enter client's 4-digit account number in Impromed Database
Ghent and Granby Vet Staff Member Entering Form Data
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First Name
Last Name
Certification
*
I certify that the individual picking up controlled meds has provided a state- or government-issued photo identification at the time of pick-up.
Verification: This Section to be Completed by Individual Picking Up Meds
By entering my name, gender and today's date below, I attest that the information contained on this form is accurate. I agree for Ghent and Granby Veterinary Hospital to keep this information on file for the sole purpose of controlled meds reporting to the Commonwealth of Virginia.
Please type your name
*
First Name
Last Name
Please select today's date
Gender
*
Male
Female
Unknown
These are the only options allowed by the Commonwealth of Virginia for dispensing controlled medications
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