Pet Vet Credit Valley Rx Request Form

Is this Prescription Request for

Pick Up

Delivery By Courier

Delivery by Mail

Pet's Name

Your Name

Your Address

City

State

Zip

Telephone

Evenings

* E-mail *Required

Name of Medication

Dosage (mg., etc.)

No. of tablets/capsules etc.

Is this a refill?

Yes

Comments or Questions for the Veterinarian:

Charge to which Credit Card?

Expiration Date

3-Digit CCV on
Back of Card

Credit Card No.:

Name on Card

Billing Address

City

State

Zip

PLEASE NOTE: All prescriptions MUST be authorized by the Veterinarian.
Please allow 5-7 days for delivery. For questions contact 905-826-1881.

* Indicates Response Required