Prescription Authorization Fax Form Pharmacy Fax: 1-866-256-8383

137 West State Street Phone: 1-800-798-2165

Our mutual client has placed an order for their pet's medication. This form can be completed then faxed, emailed or

phoned back to us. If there is more than 1 pet or medication needed, please print out the second sheet.

Pet Owner – Please print your information below

Owner ___________________________________________________ Check here if owner is over age 18 _______

First Name Last Name

Address __________________________________________________ Contact Phone ______________________

_______________________________________________________ email ______________________________

City State Zip

Please list any other medications (including OTC products) your pet is currently taking ________________________

__________________________________________________________________________________________

Please check if generic substitution is acceptable. ________________________

Veterinarian – Please print your information below

****This Area for Veterinary Use Only****

Veterinarian _______________________________________________________________________________

(Please print clearly) First Name Last Name State License #

Clinic Name _______________________________________________________________________________

_______________________________________________________________________________

Street Address

______________________________________________________________________________

City State Zip

Phone ________________________________________ Fax ______________________________________

Pet Name ____________________ Species __________ Breed __________________

Sex: F _____ S/F ____ M ____ N/M ____ Weight _______ Age _______ Allergies __________________

Significant Medical Conditions ____________________________________________________________________

Medication/Strength _____________________________________Quantity/Doses ___________ Refills ___________

Directions for Use _______________________________________________________________________________

_________________________________________________________________________ Brand Necessary ______

Veterinarian's Signature ___________________________________________ Date _________________

If you are not going to authorize this prescription for this client, please check here _________ and fax,email or

phone us. We will then contact your client and let them know the request has been denied.

Pet Name ____________________ Species __________ Breed __________________

Sex: F _____ S/F ____ M ____ N/M ____ Weight _________ Age _______ Allergies __________________

Significant Medical Conditions ____________________________________________________________________

Medication/Strength ____________________________________Quantity/Doses ___________ Refills ___________

Directions for Use _______________________________________________________________________________

_________________________________________________________________________ Brand Necessary ______

Veterinarian's Signature ___________________________________________ Date _________________

If you are not going to authorize this prescription for this client, please check here _________ and fax,email or

phone us. We will then contact your client and let them know the request has been denied.

_________________________________________________________________________________________________

Pet Name ____________________ Species __________ Breed __________________

Sex: F _____ S/F ____ M ____ N/M ____ Weight ________ Age ________ Allergies __________________

Significant Medical Conditions ____________________________________________________________________

Medication/Strength ____________________________________ Quantity/Doses ___________ Refills ___________