Prescription Information Sheet   Invoices   Statements Client Information Form

For new customers only, please fill out the Client Information Form after you have received your first prescription.  Be assured that this information will remain confidential.

Additional Services Provided by Pet Health Pharmacy

Automatic Mail Service
At your request, we can send your refills automatically.  Please contact a pharmacy technician for details.  Call toll free: 800-742-0516, (press option 2).

On-Line Services
        ●     Prescription Refills
        ●     Payments

Insurance
The Patient Information Sheet that comes with each prescription can be used to file claims with your insurance company.  Please note, your insurance company will pay you directly.  You are responsible for your account and it should be paid in full monthly to avoid delay in services.

Payments
When submitting your refills by phone or the "tan reorder/comment card," you may request to have your credit card number kept on file for future payments.  To take advantage of this service, print out the Client Information Form, by clicking on the pdf version *.  Complete the form and return by fax or mail.

Non-Safety Cap Option
To have a non-safety cap placed directly on your prescription vial(s), Pet Health Pharmacy is required to receive a signature for permission.  To take advantage of this service, print out the Client Information Form by clicking on the pdf version *.  Complete the form and return by fax or mail.

* - requires Adobe Acrobat Reader

 

 

Client Information Form
     
 

Pet's Name:
 

Pet Owner's Name:
 

Sex:

 Male  Female
 

Species:
 

Street Address:
     
 

City:
     
 

State:

      Zip:
     
 

Owner's Date of Birth:

    or   Pet Date of Birth:
     
 

Social Security No.:
     
 

Driver's License No.:
     
 

Telephone (Home):
     
 

Telephone (Business):
     
 

E-mail Address:
     
      Health Information
    Please fill in the pertinent information regarding your
    current health condition to ensure quality service.
     
 

  Pet Weight:
     
 

Allergies:
     
 

Conditions (i.e. Heart Disease, Diabetes, etc.):
     
 

Other Medications and/or Supplements:
     
   

                                         

 

 

Pet Health Pharmacy, Inc.
Toll Free Phone (800) 742-0516 · Toll Free Fax (866) 373-0030
Email: info@pethealthpharmacy.com

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