Clinic Order Form

Order Type *

Bill & Ship directly to Owner
Clinic Order
Drop Ship (clinic pays / ships to owner)

Clinic Information

Name of person placing order *

First

Last

Clinic Name *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Clinic Phone # *

Email *

Owner Information

Owner Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Only needed if filling a controlled substance or Gabapentin

Prescription Information

Is this a new prescription or a refill?

New Prescription
Refill

RX#

Pet Name *

Species *

Drug *

Strength *

Flavor / or Base if applicable

Quantity *

Form *

Sig (Instructions) *

Number of Refills *

Medical Rationale *

Controlled Substance: *

Yes
No

*If yes, Owner’s Driver’s License Information Required. Note: All orders that include controlled substances will need to be Billed and Shipped to Owner and will require a signature at delivery

Is this for a food producing animal? *

Yes
No

This drug will make a clinical difference for this patient. It is not available in this form, strength, flavor, D/C or B/O: *

Yes
No

Prescribing Doctor Name as it Appears on License: *

License #

LICENSE EXP:

DEA #

Only needed if Placing order for Controlled Substance or Gabapentin

Credit Card Information

If applicable please enter all CC information

Order a New Prescription

Clinic Information

Owner Information

Prescription Information