INITIAL/REFILL ORDER FORM

Need to place a new order or refill an existing order? Just fill out the following form, and submit it to our office. You may also call us at 913-491-6665. Please allow 24 hours for orders to be processed.

Client Name:


Patient (pet) Name:


E-mail Address:


Current Phone Number:


Current Address:


Medication Ordered:


Number of Doses:


Order to be:
Mailed ($2.00)
Picked up


Please feel free to add additional information: