BullwrinkleRX.com - Online Prescription Form

Your Discount Pet Medicine Source
Pharmacy Phone: (877) 500-9944
Pharmacy Fax: (877) 500-9950

**This is NOT a product order Form**
Please place your order on Allivet.com first and only fill out this form
if you are ordering a product that requires a veterinary prescription.

Client Pet-Vet Information

Form Required for USA orders only!
(If your order is being delivered outside the USA, no Rx is required)

* = Required Fields

Client Information

*Full Name:

*Telephone Number:

*Email Address:

Order Number:

*Address:
(Please Include Address, City, State, Zip)

Add Another Pet

Pet's Name:

Species:

Product:

Veterinarian Information

Name of Veterinary Hospital/Clinic:

Name of Veterinarian:

Clinic Address:
(Please Include Address, City, State, Zip)

Hospital/Clinic Telephone:

Hospital/Clinic Fax:
(including your vet's fax will speed processing!)

How will your pet's prescription be sent to us?
(please select one below)
Click here if you have a prescription ready.

Attached Scanned Image:
(*.jpg, *.gif, or *.pdf only) max File Size: 250kb

Add More Images

Allivet already has my prescription on File.

I'll mail or fax the prescription to you.
(Address and Fax is listed on top of this form on the header)

Click here if you do not have a prescription ready.

Need our pharmacy to contact your vet? If so, check below:

I'd like Allivet to contact my vet and obtain it.

My veterinarian will call or fax my pet's prescription in.
(Phone Number and Fax is listed on top of this form on the header)
clinic personnel only please

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