Clinic Validation Form

Clinic Name *

Email *

Phone *

Fax Number

Shipping Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Shipping Method

We will automatically ship 2 Day unless otherwise specified. (Some medications do require going 2 Day or Overnight and will be shipped this way regardless of the shipping method chosen.)

Doctors Name *

First

Last

State Veterinary License Number *

Billing Information *

Same as Shipping
Different than Shipping

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Only needed if different than shipping...

Billing Payment Method *

Monthly Bill
Credit Card Every Order
Credit Card Every Month
Email Invoice with Payment Link

If you choose an option with a Credit Card, please fill in all information so that we may process the order for you.

If CC is used for payment *

E-mail receipt
Mail receipt
No receipt needed

Monthly Statements *

E-mail statements
Mail statements
No statements needed

Full Name as it Appears on Credit Card

Type of Credit Card

Credit Card Number

Expiration Date (MM/YY)

CVC Security Code

How did you hear about us? *

Did you talk to an account representative?

Terms & Conditions *

I agree (check the box)

*CONDITIONS OF SALE* RETURNS-No merchandise may be returned without our authorization. CLAIMS- Claims for loss, damage in shipment, or any other reason must be made within five days. PRICES-Please remit payment to the above address. Past due invoices will be subject to 1.5% monthly service charge (18%APR). NSF checks are subject to a $25.00 fee. Accounts over 180 days PAST DUE go to collection and will be assessed a 40% collection fee. Storage-I have access to a refrigerator/freezer for any medications requiring such storage. By signing this form, you are authorizing Meds for Vets to do business with your company per these terms.

Terms of Service *

I agree to the terms of service.

View terms of service at www.MedsforVets.com/terms

Digital Signature *

Clear Signature

In submitting this Online Membership Application, I certify that the above information is correct and complete and do hereby agree to abide by the T.O.S.

Person Submitting Form *

First

Last

Full Name of Person that can Verify this form...

Additional Notes:

ie: change of owner, change of address, special requests.

Clinic Validation Form

A Clinic Validation Form must be filed before placing orders online. Please fill out the form below. We’ll review and approve your account as soon as possible (usually within 24 hours).

Clinic Validation Form