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Companion Animal

Customer Name                    Invoice Address                        Delivery Address  Order Date

Name:
Animal Type:
ID, if used:
Weight, if known:	Kgs:

 

Medicine Name	Pack Size	Quantity	Dosage Instructions	Animal Type

  
 
Presribing Veternary Surgeon

Name:	Qualifications:
I declare that this prescription is for animals/an animal under my care
Name of Practice/Stamp:
Address (or stamp):
Signature:	Date:

PRESCRIPTIONS ARE VALID FOR SIX MONTHS FROM THE DATE OF PRESCRIBING The medicines can only be dispensed once we have received the original copy signed by your Veterinary Surgeon.

FOR OFFICE USE ONLY: Validated ____/____/____      Validated By ____________      Rx Expiry ____/____/____

 

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