Rx Prescription Form
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1R
Prescription Form
x
CLIENT
VETERINARIAN
(please print)
(please print)
Account Name _________________________________________________________
Name ________________________________________________________________
Customer Name _______________________________________________________
License Number _______________________________________________________
Farm Name ____________________________________________________________
Address ______________________________________________________________
Customer Number ______________________________________________________
Town/City ________________________ State ___________ Zip ______________
Address ______________________________________________________________
Phone ___________________________ Fax ________________________________
Town/City ________________________ State ___________ Zip ______________
Email _________________________________________________________________
Phone ___________________________ Fax ________________________________
Signature _____________________________________________________________
Email _________________________________________________________________
Date ___________________________
Product Name _______________________________________________
Product Name _______________________________________________
Size ________________________________________________________
Size ________________________________________________________
Quantity ____________________ Number of Refills _______________
Quantity ____________________ Number of Refills _______________
Directions (check one):
Directions (check one):
o Use according to manufacturer’s label indications
o Use according to manufacturer’s label indications
o Specific use directions ______________________________________
o Specific use directions ______________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Warnings:
Warnings:
o Withhold milk for _____ hours
o Withhold milk for _____ hours
o Withhold meat for _____ days
o Withhold meat for _____ days
o Test milk before marketing
o Test milk before marketing
o Test urine before marketing animal
o Test urine before marketing animal
Product Name _______________________________________________
Product Name _______________________________________________
Size ________________________________________________________
Size ________________________________________________________
Quantity ____________________ Number of Refills _______________
Quantity ____________________ Number of Refills _______________
Directions (check one):
Directions (check one):
o Use according to manufacturer’s label indications
o Use according to manufacturer’s label indications
o Specific use directions ______________________________________
o Specific use directions ______________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Warnings:
Warnings:
o Withhold milk for _____ hours
o Withhold milk for _____ hours
o Withhold meat for _____ days
o Withhold meat for _____ days
o Test milk before marketing
o Test milk before marketing
o Test urine before marketing animal
o Test urine before marketing animal
Corporate tagline
Product Name _______________________________________________
Size ________________________________________________________
Quantity ____________________ Number of Refills _______________
Directions (check one):
PHONE
Veterinarians may submit orders by:
o Use according to manufacturer’s label indications
• Calling our pharmacy at 800-835-7451
o Specific use directions ______________________________________
(9am-6pm Eastern Time)
___________________________________________________________
• Mailing the Prescription Form to
Store tagline
___________________________________________________________
PBS Animal Health, 2780 Richville Drive SE,
MAIL
Warnings:
Massillon, OH 44646
o Withhold milk for _____ hours
• Faxing the Prescription Form to our
o Withhold meat for _____ days
pharmacy at 330-830-2764 (24/7)
o Test milk before marketing
Make a copy of this form for your Veterinarian
o Test urine before marketing animal
to fill out.
FAX
RJMforms
Make copies of this form for easy phone ordering, faxing or mailing.
Rev 01/16
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Parent category: Medical