Fillable Veterinary Registration Form printable pdf download

Veterinary Registration Form

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Complete Veterinary Registration Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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CareFirst Veterinary Pharmacy

2200 Garry Road Suite 1

Cinnaminson, NJ 08077

Office: 856-267-0528 / Toll Free: 844-822-7379

Fax: 856-267-0529 / Toll Free: 844-922-7379

E-mail:

Veterinary Registration Form

Legal Name of Business:

Name of Clinic:

Owner’s Name:

Mailing Address:

Street

City

State

Zip

Shipping Address:

(if different)

Street

City

State

Zip

Phone:

Fax:

Email:

Your Care Team

Veterinarian's Name

License Number

DEA Number

Veterinarian's Name

License Number

DEA Number

Veterinarian's Name

License Number

DEA Number

Veterinarian's Name

License Number

DEA Number

Office Contact/Office Manager:

Email:

How did you hear about CareFirst Veterinary Pharmacy?

Referral

Website

Mailer

Sales Team

Other

Compounded products you are interested in:

At CareFirst, we value our relationship with veterinarians and would like to know if you have any additional non-sterile products that

you would like us to compound for your prescribing needs:

Other Comments:

Shipping Terms: Please call us or visit our website for up to date shipping information and promotions. Orders placed after 4pm EST will be processed the next

business day. Compounded medications may require additional processing time.

Returns: At CareFirst we value your business and do what we can to keep our patients and veterinarians satisfied. We will return products received in error or

damaged in shipping. Please notify us within 10 days of receiving the shipment. All medications returned to CareFirst Specialty pharmacy must be authorized prior to

returned shipment. All unauthorized returns will be discarded and the product will not be credited. Under certain circumstances we will not be able to accept returns

due to rules and regulations including but not limited to: Control substances, Hazardous materials, sold on a non-returnable basis, expired product, products

damaged, soiled or adulterated, refrigerated or frozen products.

Thank you for choosing CareFirst Veterinary Pharmacy

Please Fax completed form to (844)922-7379 or e-mail to