Pet owner's information (Please fill out this section, then give this form to your veterinarian)


First name:_____________________  Last name:____________________    Phone:_________________


Address:_________________________________ City:__________________  State:_____  ZIP:________


Pet's name:_______________________________       Species (Dog, Cat, etc.):__________________


Order number (optional): ___________________        Order date (optional):____________________





Prescription details (to be filled out by veterinarian)


Name of drug:__________________________  Strength:_________________   Quantity:_____________


Directions:___________________________________________________      Dosage:_______________


Date of issuance:___________________________   Number of refills authorized:_________________


Clinic name, Address:________________________   Phone, Fax:_______________________________


Veterinarian name:___________________________   Signature:________________________________





Please complete top section, print out and give this form to your veterinarian to complete and fax with prescription to:  (888) 557-9629 (from licensed veterinarian only).


Alternatively, you can mail this form along with the original prescription to the following address:


Greenfield Pharmacy

1685 E. Main St., El Cajon, CA 92021

If you are sending your original prescription via postal mail, you can help to speed up processing of your order by also faxing your prescription to Greenfield Pharmacy (888) 557-9629 before mailing the original. Please include your order on both.



THIS IS NOT AN ORDER FORM. Place your order online at: