StowAg POM-VPS Application Form
The product you are ordering is a Prescription Only Medicine (eg. vaccine, fly and worm control products). To enable us to prescribe this for you, please complete the questionnaire below. Unfortunately we are unable to process your order without the completion of this form. If you are experiencing any difficulties please contact us on 01451 830 400.
Please select from the below:
Cattle and Sheep
Horses
Sheep Dip
Your Name
*
First Name
Last Name
Your E-mail
*
Phone Number
*
Product Required
*
What is the species of the animal being treated? Please select
*
Sheep
Cattle
Horse
Pigs
Goats
Cats
Dogs
Poultry
Other
Are you the registered keeper/owner of the animal(s) to be treated?
*
Yes
No
If you replied 'No' to the above, please supply the name and address of the registered keeper
Number of animals to be treated
*
What is the weight of animals to be treated?
Flock/Herd Number
*
Holding Number
*
Have you used this product before?
*
Yes
No
Have any of the animals to be treated ever suffered an adverse reaction?
*
Yes
No
Please acknowledge you will read the data sheet before administration and are aware of the appropriate safety precautions
*
Yes
No
Would you like a phone call from an SQP to discuss safe administration of this product or for any further advice? (If yes, please enter Phone Number below)
*
Yes
No
Name
*
First Name
Last Name
Your E-mail
*
Phone Number
*
Product Required
*
Are you the registered keeper/owner of the horse(s) to be treated?
*
Yes
No
If you replied 'No' to the above, please supply the name and address of the registered keeper
Please confirm your horse been signed out of the food chain in the passport?
*
Yes
No
Is the Horse over 6 months?
*
Yes
No
Number of horses to be treated
*
What is the weight of the horses to be treated?
Have you used this product before?
*
Yes
No
What product did you use last time and when?
*
Have any of the horses to be treated ever suffered an adverse reaction?
*
Yes
No
Please acknowledge you will read the data sheet before administration and are aware of the appropriate safety precautions
*
Yes
No
Would you like a phone call from an SQP to discuss safe administration of this product or for any further advice? (If yes, please enter Phone Number below)
*
Yes
No
Name
*
First Name
Last Name
Your E-mail
*
Phone Number
*
Product Required
*
Are you the registered keeper/owner of the animal(s) to be treated?
*
Yes
No
If you replied 'No' to the above, please supply the name and address of the registered keeper
Flock/Herd Number (required field)
Holding Number (required field)
Dip Certificate (Required for all Gold Fleece Dip Orders)
*
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Number of animals to be treated
*
What is the weight of animals to be treated?
Have you used this product before?
*
Yes
No
What product did you use last time and when?
*
Have any of the animals to be treated ever suffered an adverse reaction?
*
Yes
No
Please acknowledge you will read the data sheet before administration and are aware of the appropriate safety precautions
*
Yes
No
Would you like a phone call from an SQP to discuss safe administration of this product or for any further advice? (If yes, please enter Phone Number below)
*
Yes
No
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