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Veterinarian Herb and Supplement Auth

Thank you for using our apothecary as your online dispensary!
Please complete the below information so that we may process your request.

Patient Information:

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Client Information:

Supplement Information:

List
Supplement:
Dosing:
Quantity:
Refills:
 
**Please leave blank (Dosing) if you would like us to make suggestions based on body weight**
** We will make refills PRN unless otherwise specified**
Please list any special requests or additional information that you would like us to know prior to processing this request.

Contact Information:

This is my patient and I hold the valid veterinarian-patient-client-relationship (VPCR)
MM slash DD slash YYYY

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