New Veterinary Prescription Request Form
Please provide your contact info & your veterinarian's info and we will contact your veterinarian to request a new prescription on your behalf.
Patient Information
Please provide us with your personal information
Pet's name
*
Pet's first name
Pet's species
*
e.g. Cat, Dog, Bird, Ferret, Horse, etc.
Owner's first name
*
Owner's first name
Owner's last name
*
Owner's phone number
*
Please enter a valid phone number.
Owner's email address
example@example.com
Prescription Information
Please provide us with details about your pet's prescription that you are interested in having us fill for you.
Drug Name
*
Please enter the name of the drug
Dosage Form
*
i.e. Capsules, Oral Liquid, Cream, Ointment, Eye Drops, Injectable, etc.
Strength/Concentration of medication
i.e. 3mg, 5mg/mL, 10mg/0.1mL etc.
Typical quantity dispensed
e.g. 30mL, 60 days supply, etc.
Veterinarian's Information
Please provide us with your veterinarian's information so we may ask them for a new prescription on your behalf.
Veterinarian's name
*
e.g. Dr. Smith, Dr. Jane Smith, Etc.
Name of the clinic or organization that your doctor works for
*
e.g. "A Street Animal Clinic," "Banfield Pet Clinic," 'VCA Pet Clinic," etc.
Clinic phone number
*
Please enter a valid phone number.
Clinic fax number
Please enter a valid fax phone number.
Please confirm that you are human by completing a simple math problem. What is 7 plus 13?
*
Submit
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