Lums Pond Animal Hospital Rx Request
PLEASE NOTE: THIS SERVICE IS ONLY FOR CLIENTS OF LUMS POND ANIMAL HOSPITAL.
Pet's Name
Date
Your Name
Your Address
City
State
Zip
Telephone
Evenings
Cell Phone
E-mail
Name of Medication
Dosage (mg., etc.)
No. of Tablets/Capsules, etc.
Is this a refill?
Yes
No
Comments or questions for the Veterinarian
Charge to which credit card?
Visa
MasterCard
American Express
Discover
Credit Card No.
Expiration Date
CCV (Security No.)
Name on Card
Billing Address (if different from above)
City
State
Zip
The amount to be charged to your credit card will be sent to you by e-mail
at the time the prescription is authorized by the Veterinarian.
Please click on "SUBMIT" below to send your order.
*
Indicates Response Required
Report Abuse