Patient History Form

Patient History Form 2017-05-17T16:51:08+00:00

For customers only, please fill out the following Customer Information Form after you have received your pet’s first prescription or wish to update your information with us.

Non – Safety Cap Option

To have a non-safety cap placed directly on all of your prescription vial(s), Pet Health Pharmacy is required to receive a signature for permission. To take advantage of this service on ALL prescription vials, print out the Customer Information Form. Complete the form and return by fax or mail.

Mail or fax all forms and photocopies to:

12012 N. 111th Avenue
Youngtown, AZ 85363

Fax: 866.373.0030

Other Pages:

Prescription Information

Refill A Prescription

Auto Ship

Customer Information

(Required by law in some states)

Health Information

(Heart Disease, Diabetes, etc.)

Be assured that this information will remain confidential.