Petmeds2go.com Prescription Request Form
1) Print out this form and give it to your veterinarian for their convenience. If you already have a completed prescription from your veterinarian you can mail, fax, or scan it to us.
Fax: 1-866-256-8383
Mail: Petmeds2go.com
Dike, IA 50624
Email: prescriptions@petmeds2go.com
2) A prescription alone does not count as an order. You need to place your order on-line.
Client Name: ________________________________________________
Client’s Address: ________________________________________________
________________________________________________
Client’s Phone #: ________________________________________________
Patient Name: _________________________ Gender: _______________
Species: _________________________ Age: __________________
Breed: ________________________________________________
Veterinarian’s Name: ________________________________________________
Veterinarian’s Address: ________________________________________________
________________________________________________
Veterinarian’s Phone: _______________________ Fax: ____________________
Medication: ________________________________________________
Directions: ________________________________________________
________________________________________________
_______________________ Refills: __________________
_____________________________________________________________________
D.V.M. Signature D.V.M. Printed Name Date