Prescription Request Form For controlled medications, please contact the pharmacy directly at (866) 784-6915​ Step 1 of 3 - Client Information 0% Client Name(Required) Client Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sorry! At the moment, we are not shipping to your region.Client Phone Number(Required) Client Email(Required) Patient Name(Required) Patient Species(Required)CanineFelineOtherPatient D.O.B(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Compounding Medications Medications Strength Dosage Form Flavor Quantity Price Refills Directions for Use Actions Edit Delete There are no Medications. Add Medication Maximum number of medications reached. Comments Prescriber Name(Required) HiddenPrescriber Email(Required) HiddenLicense Number(Required) HiddenState(Required)Select License StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPractice Name Phone Number(Required) Practice Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sorry! At the moment, we are not shipping to your region.Signature(Required) Reset signature Signature locked. Reset to sign again November 3, 2024 7:24 pm CSTBilling/Shipping(Required) Bill practice and ship to client Bill and ship to practice Bill and ship to client PetScript will be contacting the client for payment. Consent(Required) By checking this box, I am authorized to execute this order and understand that use of the product will be conducted in accordance with applicable law. I have also reviewed this information and approve this prescription on rxpetscript.com from PetScript ProLab Pharmacy. Would you rather fax it in? Download Form Pharmacy Catalog PetScript Pharmacy 3020 Lamar Ave, Paris, TX, 75460 Phone: 866-784-6915 | Fax: 903-785-1357 Email: [email protected] Privacy Policy | Disclaimer