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Farm Animal/Equine
Customer Name Invoice Address Delivery Address
Order Date
Medicine Name
Pack Size
Quantity
Dosage Instructions
Animal Type &
Withdrawal Times
No. Repeats
Type:
Milk:
Meat:
No. Repeats
Type:
Milk:
Meat:
No. Repeats
Type:
Milk:
Meat:
No. Repeats
Type:
Milk:
Meat:
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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