Valuevet.com Prescription Request Form

  1. Print out and hand this form to your veterinarian for their convenience. If you already have a completed prescription from your veterinarian you can send or fax that form to us, after drawing a line thru prescription and writing Valuevet on the form.

Fax it to: 319-989-2220
Mail it to: Valuevet, PO Box 217, Dike, IA 50624

  1. 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: _________________________________________________________
  _________________________________________________________
Dispensing Directions: _________________________________________________________
  _________________________________________________________
Product Name Quantity Unit
______________________________________________ ________ ________________
______________________________________________ ________ ________________
______________________________________________ ________ ________________
Client's Name
and Address:		 ______________________________________________________
  ______________________________________________________
  ______________________________________________________
Client's Phone #: ______________________________________________________

Veterinarian's
Signature :

 ______________________________________________________
Refills: ______________________________________________________
Label: ______________________________________________________