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Rx Requests:
Please fill in the following details. By completing this request you affirm that dosage has not changed AND that the patient is doing well. If NOT, please call us at (562) 435-6331 instead. (Note: in order to complete this form, you will need the prescription in front of you - the rx number requested on this form is the 5 digit number below our address on the prescription label.)
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Your Name
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Patient (Pet) Name
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5 Digit RX Number (From RX Label)
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RX Name
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I received the medication from The Family Vet.
Yes.
No.
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I affirm that dosage is as directed on label.
Yes.
No.
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I affirm that the patient above is doing well.
Yes.
No.
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Email:
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Phone:
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Additional comments/notes
* indicates mandatory field
