Client information form for prescription items:
Interceptor®, Revolution®, and Heartgard®

Please Fill in the Required Fields
(*) Indicates required field.

We must have your account login and password to add you to our database.

* Customer Name:
* Login
* Password
* Address Line 1:
Address Line 2:
* City:
* State:
* Zip:
* Home Phone:	Include Area Code
* Daytime Phone:	Include Area Code
* E-mail Address:
Regular Veterinarian:
Veterinarians Phone #:	Include Area Code
* Pet's Name:
* Birthdate:
* Dog or Cat?:	Dog     Cat
* Breed:
Last Physical Examination:
Last Heartworm Test:
Results of Heartworm Test:	Positive  Negative

List any health problems your pet has: List any medications your pet is currently on: Describe any reactions your pet has had to medication or flea control products: Is your pet taking medication to prevent Heartworm infection? If so, which product? If this pet has serious medical problems then please FAX us a copy of the current medical records for review. FAX #: 253-847-8713 You may add an additional pet below. If you are finished scroll to the end of this page to submit the history form.
Second Pet Information If no second pet please skip this section.
Pet's Name:
Birthdate:
Dog or Cat?:	Dog     Cat
Breed:
Last Physical Examination:
Last Heartworm Test:
Results of Heartworm Test:	Positive  Negative

List any health problems your pet has: List any medications your pet is currently on: Describe any reactions your pet has had to medication or flea control products: Is your pet taking medication to prevent Heartworm infection? If so, which product? If this pet has serious medical problems then please FAX us a copy of the current medical records for review. FAX #: 253-847-8713 Click below to submit or clear form.