Submit Rx | VDCrx

Prescription Submission Form

Prescription Submission Form

Practice
Owner
Pet
Medication

Practice Name

Practice - Phone Number

Practice - Street Address

Apartment, suite, etc

Practice - City

Practice - State/Province

Practice - ZIP / Postal Code

Practice - Country

Prescribing Veterinarian

Pet Parent First Name

Pet Parent Last Name

Pet Parent Phone

Practice - Street Address

Apartment, suite, etc

Practice - City

Practice - State/Province

Practice - ZIP / Postal Code

Practice - Country

Pet Name

Pet DOB

Pet Species

Pet Gender

Pet Allergies

Script Medication

Script Strength

Script Formula Form

Days Dispensed

Number of refills

Notes

Where We Deliver

We cover all of California and can ship for next-day Delivery!