Veterinary Prescription Pad

Veterinary Prescription Pad
**Please note: A pharmacy team member will call to verify all prescriptions received via this format.
Date*

MonthDayYear
Date
Veterinarian Name*
Veterinarian DEA*
Clinic Name*
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinic Phone*
Format: (000) 000-0000.
Clinic Email (if you would like to receive a copy of this Rx)
example@example.com
Animal/Herd Name *
Species*
Animal DOB*
Owner Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner Phone*
Format: (000) 000-0000.
Drug Name/Compound Name and Strength*
Directions for Use*
Quantity to Dispense & Refills (if desired)*
Veterinarian Signature*
Should be Empty: