New Client Written Prescription/Online Pharmacy New Client Written Prescription/Online Pharmacy Name * Name First Name First Name Last Name Last Name Email * Phone * Animal Name * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal I hereby request a prescription for medication(s) for my pet so that I can purchase these products from an outside pharmacy. I have been informed that the following risks exist when I obtain these products from a source other than my veterinarian. There is possibility that the prescription drugs received from these vendors may be counterfeit or may not have been approved by the FDA or EPA. These medications could be outdated, mislabeled, or improperly stored. Pharmacists are not trained in veterinary medicine and medications could be under dosed, over dosed, or contain ingredients that are not safe for pets. The number of tablets or capsules, milligram size of the unit, volume and/or concentration of liquid and number of authorized refills may differ from that prescribed by the attending veterinarian. The manufacturer’s warranties or guarantees for these products may not be valid. This means if your pet’s condition is not effectively treated with the product(s), manufacturers may not stand behind their products or product liability procedures. Additionally, the owner and veterinarian at this facility may be unable to assist you in claims against those manufacturers. I understand that this written prescription is a legal document and should be treated as such. I further understand that this document cannot be re-issued if lost or misplaced until refill date if applicable. Also, in order to cancel this outside prescription and have indicated medications filled at this facility within the prescription(s)’ (or their refills’) time period I must return the prescription document to this facility to be disposed of. I have read and understand the above, accept these risks, and am aware that this facility cannot accept any financial responsibility for paying for or reimbursing me for any treatments required as a result of the use of products purchased outside of this establishment. In the absence of negligence, I agree to hold this veterinary practice harmless for any deleterious effects or lack of effectiveness of drugs or vaccines purchased from any other source. Signature * signature keyboard Clear Date * Submit Captcha If you are human, leave this field blank.
