Prescription Request Form

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					                                                                                    Fax: (866) 259-5824
     Pet Pharmacy Plus
                                Prescription Request Form
              Please complete and fax back toll-free to (866) 259-5824.
   Our mutual client, listed below, has placed an order with us for their pet's medication.
   Please complete the information below and fax this Rx confirmation from to us within
   24 hours so we may process the order in a timely manner. Thank you.
                                            Customer Information
 Order Number:                                                    Date:
 Owner's Name:
 Pet(s) Name(s):

 Address:                                                   Phone:



                                                    Vet Approval
 Medication/Dosage:
            Number of Refills           0      1      2      3     4      5    6    7       8    9     PRN

 Medication/Dosage:
            Numb er of R efills          0     1      2       3     4      5   6     7      8     9     PRN

 Medication/Dosage:
            Numb er of R efills          0      1     2       3     4      5    6     7     8     9     PRN
Instructions:




                                                                        Hospital Address:
 Veterinarian's Phone Number:

 Vet erinarian's Fax Number:

 Veterinarian's Signature:

 If there is a medical condition in the processing of this request, please indicate below so we may inform the pet's
 owner of the delay and the reason of the delay in processing their medication request. Thank you.

 Decline Reason: