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800.742.0516

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. 

Safe SecureBe assured that this information will remain confidential.

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 (Heart Disease, Diabetes, etc.):

 

Other Medications / Supplements:

     
   

                                         

 

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 if your medication is covered.  Please note, your insurance company will pay you directly.

Payments

We accept payment in a variety of forms. Options include: credit card, check, cash, or money order. You may also 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
 
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