Valuevet.com Prescription Request Form

1.  Print out and hand this form to your veterinarian for their convenience. If you have already have a completed prescription from your veterinarian

you can send or fax that form to us, after drawing a line thru the prescription and writing Valuevet on the form.

Fax it to:   888-989-2220

Mail it to: Valuevet, PO Box 217, Dike, Iowa 50624

2.  A prescription alone does not count as an order. We need you to either send an order by either mail or fax, or place your order on-line.

Patient Type:  Pet                            Species: ______________________________

Pet’s Name:  _________________________________________________________________________________

(If you have more than one pet, hyphenate between names)

Gender: _____________________________                                   Age: _______________________

Breed:  ___________________________________________________________________________

Vet’s Name:  _______________________________________________________________________

Vet’s Phone #:  _____________________________________________________________________

Vet’s Address:  _____________________________________________________________________

                              ______________________________________________

                              ______________________________________________

Product Name    Quantity            Unit

             ____________________________     __________       __________

             ____________________________      __________      ___________

             ____________________________      ___________     ___________

Dispensing Directions:    ______________________________________________

                                          _______________________________________________

Client’s Name

                    and Address:       ________________________________________________

_________________________________________________________________________

                                                       __________________________________________________________________________

Client’s Phone #:      __________________________________________________________________________

                    NOTE TO VETERINARIAN:  IF BRAND NECESSARY – WRITE BRAND NECESSARY ON PRESCRIPTION

                    Veterinarian’s Signature:  _________________________________________________   Date: _______________________

                     Refills:  ______________________________