Palm Plaza Pet Hospital Prescription Request

PLEASE NOTE: THIS SERVICE IS ONLY FOR CLIENTS OF PALM PLAZA PET HOSPITAL.

Date

Your Name

Your Address

City

State

Zip

Telephone

Evenings

Cell Phone

* E-Mail (Required)

Name of Medication

Dosage (mg., etc.)

No. of Tablets/Capsules, etc.

Is this a refill?

Yes

Comments or questions for the Veterinarian

Charge to which credit card?

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.
If you have further questions, please contact us at (661) 272-4551.

Please click on "SUBMIT" below to send your order.

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