County Line & Heritage Veterinary Hospital Prescription Special Request

* Pet's Name

* Your First Name

* Your Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

Evening Telephone

* Email Address

* Name of Medication

Dosage (mg, oz, etc)

Number of tablets/capsules, etc.

* Is this a Refill?

Yes

No

Comments or Questions for the Veterinarian

IF YOU ARE ONE OF OUR HMO MEMBERS, PLEASE GIVE US YOUR POLICY EXPIRATION DATE

* Name on Credit Card

* Credit Card Type

* Credit Card No.

* Expiration Date (mm/yy)

* CCV (3-digit number on back of card)

Billing address is same as above

yes

Billing Address If Different From Above

Address Line 2

City

State

Zip Code

Phone Number

Please Note: All prescription requests MUST be authorized by the Veterinarian.

Please allow 5 - 7 days for delivery. For questions, contact (856) 988-0022

* Indicates Response Required