The Pet Oncologist | Pharmaceutical Prescription Form

Pharmaceutical Prescription Form

Oral Chemotherapy
Requested Date

DayMonthYear
Date (DD/MM/YYYY)
Time AM/PM Option
Prescribing Veterinarian
Veterinarian*

First NameLast Name
Hospital Name*
Licence Number*
Hospital Address (If previously provided or included on the script, you may leave this field blank)

Street Address

Street Address Line 2

CityState

Post Code
Phone*
Patient Information
Pet*

First NameLast Name
Species*
Age or DOB (DD/MM/YYYY)*
Sex*
Weight (kg)
Owner*

First NameLast Name
Owner's Address (If this is included on the script you will provide, leave blank)

Street Address

Street Address Line 2

CityState

Post Code
Prescription Submission Instructions
Please upload the script(s) for the requested medication(s).
- You may fill in this template or use an electronic prescribing system (e.g. RXWorks or EzyVet), ensuring compliance with the Medicines and Poisons Act 2021 and the Veterinary Surgeons Board regulations of your state.
- If you are using an approved electronic prescription management system, a physical copy of the prescription is not required. However, if you are using this online prescription form or any other non-approved electronic system, please ensure the prescription is printed, signed with your handwritten signature, and sent within 7 days after sending a digital copy. We will provide you with a prepaid return envelope with your order to ensure the timely return of the original prescription.
Upload Script(s)

Alternatively, you can complete this online ordering form and email the script(s) to info@thepetoncologist.com
Cancelof

Medicine*

	Name & Dosage	Quantity	Label Instructions
1
2
3
4
5
6

Label Instructions:

If the information is provided on the script, you leave "Label Instructions" field blank.

For orders intended for hospital usage without a specific patient, please label the instructions with "FOR EMERGENCY HOSPITAL USAGE" and provide a script accordingly.
Special instructions / Comments
Declaration*

I confirm that I am a registered veterinarian in Australia with the authority to prescribe the chemotherapy drugs listed on the provided prescription(s), in compliance with the Veterinary Surgeons Board regulations and relevant legislation, including the Medicines and Poisons Act 2021.I declare that all information provided on this form is accurate and complete to the best of my knowledge.I acknowledge that these drugs must be used in accordance with applicable legislation and guidelines, and I accept full responsibility for their appropriate use.I understand that oral chemotherapy medications, such as CCNU (Lomustine), dispensed outside of sealed blister packs are non-refundable. This policy ensures compliance with safety, storage, and regulatory requirements.By signing this electronically, I confirm that I am the authorised veterinarian prescribing and ordering this drug in compliance with the Veterinary Surgeons Act in my state.If a prescription is not submitted through an approved electronic prescribing system, I will provide a signed hard copy prescription to The Pet Oncologist within 7 days of sending the digital copy.
Do you need to send us a signed hard copy prescription?*
Click "Yes" if you are not using an approved electronic prescribing system (e.g. RXWorks or EzyVet)
Signature*

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Date Signed*

DayMonthYear
Date (DD/MM/YYYY)
Time AM/PM Option
Final Steps:

Please ensure you have completed this form, along with the online ordering form, by clicking here.

If you have any questions or concerns, please email us at info@thepetoncologist.com
Should be Empty:

Pharmaceutical Prescription Form

Prescribing Veterinarian

Patient Information

Prescription Submission Instructions