Business Contact Information

Owner First Name

Owner Last Name

Title

Ordering Contact

Position

Clinic Name

(This will be your Username)

Phone

Fax

(Optional)

Address

City

State

Zip Code

Password

Confirm Password

Monthly Statement Settings

Please mail my monthly statement via USPS

Please E-mail my monthly statement

Please charge my credit card for my orders

Name

(As appears on the credit card)

Expiration date

CVV (What's this)

Credit card number

Billing Address

City

State

You may enter or update your credit card at checkout

Please send me updates about

Canine

Feline

Avian

Equine

Exotic

Other

I agree with the IN-CLINIC USE AGREEMENT

If you have any questions or concerns, please contact our pharmacist-in-charge for more information.

This agreement states that any compounded preparation (prescription drugs) sold for in-clinic may only be administered to the patient and may not be dispensed to the patient or sold to any other person or entity except patients in the veterinarian's office, or on the patient's premises. The prescription drugs are only used to meet the needs of the veterinarian's patient. The veterinarians must also comply with laws relating to the practice of veterinary medicine and all state and federal laws relating to prescription drugs.

You, the veterinarian must include on a patient's chart, medication order, or medication administration record the lot number and beyond-use date of a compounded preparation administered to the patient.

All patients must be told that all adverse reactions should be reported to our pharmacist.

In the event of a recall for a compounded preparation the veterinarian must assist in notifying the patients with information about the recall.

Prescribing Doctor's Information

Doctor's First Name

Doctor's Last Name

License No.

(Optional)

Signature

(Optional)

(This signature will be used only for authorization of your patient prescription. We will not share/sell this information anywhere.)

Custom Signature

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