Pet Vet Eastside 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 905-662-6719.

* Indicates Response Required