Pet Health Pharmacy - Customer Information Form


Prescription Information Sheet Invoices Customer Information Form
For customers only, please fill out the Customer Information Form after you have received your first prescription or wish to update your information with us. 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 Insurance The Prescription 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. Payments You may request to have your credit card number kept on file for future payments. To take advantage of this service, print out the Customer 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 Customer Information Form by clicking on the pdf version . Complete the form and return by fax or mail. - requires Adobe Acrobat Reader
Customer Information Form

	Pet's Name:
	Sex:	Male Female
	Species:
	Pet Owner's Name:
	Street Address:

	City:

	State:	Zip Code:

	Owner's Date of Birth:

	Social Security and/or Driver's License No.:	(Required by law in some states)

	Telephone (Home):

	Telephone (Business):

	Telephone (Cell):

	Email Address:

			Health Information
		Please fill in the pertinent information regarding your Pet's
		current health condition to ensure quality service.

	Pet's Weight:

	Pet's Date of Birth:

	Allergies:

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

	Other Medications and/or Supplements:


Pet Health Pharmacy Toll Free Phone (800) 742-0516 · Toll Free Fax (866) 373-0030 Email: info@pethealthpharmacy.com Home \| About Us \| Medications \| FAQ's \| Refills \| Billing \| Contact Us Copyright © 2004-2011 Pet Health Pharmacy. All rights reserved. Pet Health Pharmacy is a division of Women's International Pharmacy, Inc.