Prescription Form

Pet owner's information (Please fill out this section, then give this form to your veterinarian)

First name: ___________________ Last name: ______________________ Phone: ______________

Street: _______________________ City:_______________________ State:____ ZIP:________

Pet's name __________________________________ Species (Dog, Cat, etc.): __________________

Order number (if known):________________________ Order date (if known): _________________

If this is a refill, please include Rx Refill # from your medicine label: ________________

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Prescription details (to be filled out by veterinarian)

Name of drug:__________________________________ Strength:______________ Quantity:______

Directions:__________________________________________________________________________

Dosage:____________________ Date of issuance:___________ Number of refills authorized:_____

Phone, Fax:_______________________________ Clinic name, Address:_______________________

Veterinarian name:__________________________ Signature:______________________________

To expedite processing, this form should be faxed with the prescription taped here.

Please complete top section, print out and give this form to your veterinarian to complete and fax with prescription to: (866) 787-1185 (alternate fax number: 866-787-1177)

Alternatively, you can mail this form along with the original prescription to the following address:

Pet's Choice Pharmacy

c/o DogCatEtc.com

714 5th Street, Fairbury, NE 68352

THIS IS NOT AN ORDER FORM. Place your order online at: www.DogCatetc.com