Client / Pet Information (Please complete this form if you are ordering a prescription medication or product)
Please fill in as much information as possible to facilitate the pharmacy in filling your prescription

Order No:

Your Name: * Required

Your Area Code / Phone Number (used to identify the patient record / order):-

Your Email Address (used to identify the patient record / order):

Pet Owner's Name as it is Listed at Veterinary Hospital or on the Prescription:* Required
1. Pet's Name:  Breed:   Sex:
2. Pet's Name:  Breed:   Sex:
3. Pet's Name:  Breed:   Sex:
4. Pet's Name:  Breed:   Sex:
Name of Veterinarian:
Name of Veterinary Hospital/Clinic:
Hospital/Clinic Phone: - Fax:
 
My pet's prescription will be sent by:

Mail.  To ensure rapid processing of your order, also fax your prescription to PetPharmacy Rx (888) 557-9629 before mailing the original.  Please include your order number on both.

Veterinarian will fax prescription to PetPharmacy Rx (888) 557-9629.
Veterinarian will call the prescription in to PetPharmacy Rx (619) 270-1207, (888) 455-7289.
I would like PetPharmacy Rx to fax a Prescription Request Form to my veterinarian (To facilitate this request, please provide hospital/clinic fax number in the box above).

Please Note:  The pharmacy is unable to offer prescription medications in Idaho and Louisiana while licensing is being upgraded.
 
Please list which medication is for which pet:
 
Automatic Refill Request
Automatic Refills ? Yes, automatically send me refills when I need them.
If yes, we will automatically send your pet's medication when it is due for refills. Your credit card will be charged when the medication is shipped.  You can cancel your Automatic Refills at any time by email or phone (800) 668-9698.  Please complete the following boxes so that we'll know exactly the item, quantity and frequency of refills you would like.
 
Send Item    Quantity    Send Every
Send Item    Quantity    Send Every
Send Item    Quantity    Send Every
Send Item    Quantity    Send Every
 
Note: PetPharmacy Rx will automatically send your veterinarian a Prescription Request Form when additional refills are needed.

Note: OTC items and Rx items may ship separately and from different locations.