Order Form (for Canadian Customers)
Please complete this form and fax it along with the prescription to us at the fax# above.

Client Information: (Please Print)

Name of pet owner: _________________________________________________

Name of pet: ______________________________________________________

Address:___________________________________________________________

City:______________________Prov:______________Postal Code_____________

Telephone:______________________ Email:______________________________

Credit Card No.:____________________________________Expiry____________

Name on Credit Card_____________________________

Veterinarian Information (Please Print)

Name: _____________________________________________________________

Office Address:_______________________________________________________

City:_______________________Prov:_____________Postal Code______________

Telephone:___________________ Fax:______________________

 

Owner's Signature:_______________________________Date:_________________