Controlled Substance Form

Controlled Substance Receipt Form

For All Controlled Substance Prescriptions
Your pet/foster animal was prescribed a controlled substance. By Nebraska/Iowa law, veterinarians are required to report any and all controlled substances dispensed to the Nebraska Prescription Drug Monitoring Program (PDMP). As such, please fill out the following required information below. Please note information must be that of the individual recieving the dispensed medication.

Furthermore, per NE LB 931, Sec. 5. (1) ... "the individual shall display a valid driver's or operator's license, a state identification card, a military identification card, an alien registration card, or a passport as proof of identification."
Owner Name*

First NameLast Name
Owner Birth Date:*

MonthDayYear
Date
Owner's Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Signature of Receiving Party*

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Owner ID Information*
Pet Name*
Pet ID Number*
Configurable list*
Payment Type*

CashCredit/Debit CardOther (Please Specify)
Should be Empty:

Controlled Substance Receipt Form