Medi-Vet - Prescription Form

Greenfield Pharmacy
Medi-Vet Animal Health Affiliate Pharmacy
Prescription Form
Please Fax: (888) 557-9629
Vet Phone-in Line: 888-455-7289 (619) 270-1207
(Form for use only by a licensed veterinarian)
Customer Phone Line: 800-668-9698

Pet Owner:		Date:
Address:		City:
State:		Zip Code:
Phone:		Pet:
Breed:		Sex:
Online Order Number (if available):

Refill - 0 - 1 - 2 - 3 - 4 - 5 - 6 - PRN

[ ] Label

Dx/Tx:

Hospital/Clinic:

Signature:
Veterinarian’s Name (print):	, DVM/VMD
DVM/VMD License:

Phone:

Fax:

How to use this form:

Print and hand this form to your veterinarian for their convenience. Your veterinary hospital can then fax the form to Greenfield Pharmacy 1-888-557-9629.
New York veterinarians cannot use this form.. Instead, the New York Official Prescription Form must be submitted.
Louisiana, Idaho Residents: Prescription items are not available to residents in these states.
Sending in only the prescription without an order does not constitute an order. An order must also be submitted either by mail, fax, email, or it can be placed online.