PRESCRIPTION AUTHORIZATION FAX FORM Pharmacy (toll …...Step 2: PRINT Veterinary Rx Authorization...

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PRESCRIPTION AUTHORIZATION FAX FORM Pharmacy (toll free) Fax # 844-922-7379 (for veterinary use only) Dear Pet Owner, Thank you for choosing CareFirst Veterinary Pharmacy. To order a prescription medication, a prescription from a US-licensed veterinarian is required. For your convenience, and for the convenience of your veterinarian, please feel free to utilize the following form. Please print this PDF document and fill out your contact information. IMPORTANT: Deliver the fax form to your veterinarian for further processing. State and Federal pharmacy laws stipulate that pet prescriptions may only be faxed to a licensed pharmacy from a US-licensed veterinarian. Confidentiality Notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange the return of this document. PET OWNER Step 1: You can call us to setup a new account for your pet or proceed to Step 2. Step 2: PRINT Veterinary Rx Authorization FAX Form & fill in your contact info under Section A - Pet Owner Step 3: BRING this to your veterinarian for authorization. (We cannot accept any prescriptions unless faxed from a veterinarian). VETERINARIAN Step 4: COMPLETE FORM Step 5: FAX to CareFirst Veterinary Pharmacy to 1-844-922-7379 or if you prefer you may call in the prescription verbally over the phone at 1-844-822-7379 Ordering from CareFirst is easy once we get your pet’s prescription on file. If you have any questions, or wish to place your order by phone, feel free to call us any time at 844-822-7379. Thank You, CareFirst Pharmacy Staff CareFirst Veterinary Pharmacy 2200 Garry Road Suite 1 Cinnaminson, NJ 08077 Office: 856-267-0528 / Toll Free: 844-822-7379 Fax: 856-267-0529 / Toll Free: 844-922-7379 e-mail: fax@cfspharmacy.com www.cfspharmacy.com

Transcript of PRESCRIPTION AUTHORIZATION FAX FORM Pharmacy (toll …...Step 2: PRINT Veterinary Rx Authorization...

  • PRESCRIPTION AUTHORIZATION FAX FORMPharmacy (toll free) Fax # 844-922-7379

    (for veterinary use only)

    Dear Pet Owner,

    Thank you for choosing CareFirst Veterinary Pharmacy.

    To order a prescription medication, a prescription from a US-licensed veterinarian is required. For your convenience, and for the convenience of your veterinarian, please feel free to utilize the following form. Please print this PDF document and fill out your contact information.

    IMPORTANT: Deliver the fax form to your veterinarian for further processing.State and Federal pharmacy laws stipulate that pet prescriptions may only be faxed to a licensed pharmacy from a US-licensed veterinarian.

    Confidentiality Notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange the return of this document.

    PET OWNER

    Step 1: You can call us to setup a new account for your pet or proceed to Step 2.

    Step 2: PRINT Veterinary Rx Authorization FAX Form & fill in your contact info under Section A - Pet Owner

    Step 3: BRING this to your veterinarian for authorization. (We cannot accept any prescriptions unless faxed from a veterinarian).

    VETERINARIAN

    Step 4: COMPLETE FORM

    Step 5: FAX to CareFirst Veterinary Pharmacy to 1-844-922-7379 or if you prefer you may call in the prescription verbally over the phone at 1-844-822-7379

    Ordering from CareFirst is easy once we get your pet’s prescription on file. If you have any questions, or wish to place your order by phone, feel free to call us any time at 844-822-7379.

    Thank You,CareFirst Pharmacy Staff

    CareFirst Veterinary Pharmacy2200 Garry Road Suite 1Cinnaminson, NJ 08077

    Office: 856-267-0528 / Toll Free: 844-822-7379 Fax: 856-267-0529 / Toll Free: 844-922-7379

    e-mail: [email protected]

  • VETERINARY PRESCRIPTION AUTHORIZATION FAX FORM Pharmacy (toll free) Fax

    844-922-7379(for veterinary use only)

    ATTENTION VETERINARIAN: Thank you for choosing CareFirst to fill a prescription for your client’s medication(s). If you have any

    questions, please call 844-822-7379.

    SECTION A: PET OWNER – please print information below

    OWNER

    BILLING ADDRESS

    PHONE

    First Name Last Name Customer Number – (optional)

    City State Zip

    EMAIL

    SECTION B: VETERINARIAN – please print prescription info (or attach RX below) and fax to 844-922-7379

    ***** This Area for Veterinary Use Only *****

    VETERINARIAN

    CLINIC

    PHONE

    First Name Last Name

    FAX

    State License #

    City State Zip

    Office Name

    Pet's Name Species Weight

    Compounded Medication

    Strength QTY per item Addt’l # of Refills

    1

    Directions for Use:

    Veterinarian’s Signature(Please review directions and number of refills)

    Name Date

    Confidentiality Notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended

    only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If

    you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is

    strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange the return of this document.

    Address

    PET'S NAME

    SHIPPINGADDRESS

    PREFERRED SHIPPING METHOD

    Ground Second Day Air Overnight

    Bill to

    Office

    Patient

    Ship to

    Office

    Patient

    Sex Age/DOB

    Dosage Form Number of item

    Please indicate any known allergies/medical conditions:

    Please list any additional medication that the patient is taking:

    (if different)

    DEA # (for controls)

    Email

    Other

    Pet's Name Species Weight

    Compounded Medication

    Strength QTY per item Addt’l # of Refills

    2

    Directions for Use:

    Sex Age/DOB

    Dosage Form Number of item Other

    First Name: Last Name: Customer Number optional: PETS NAME: Address: SHIPPING 1: SHIPPING 2: City: State: Zip: undefined: EMAIL: Ground: OffSecond Day Air: OffOvernight: OffFirst Name_2: Last Name_2: State License: Office Name: City_2: State_2: Zip_2: PHONE: FAX: Pet Name: Species: Weight: AgeDOB: Directions for Use: Pet Name_2: Strength_2: Dosage Form_2: QTY per item_2: Number of item_2: Addtl of Refills_2: Please indicate any known significant allergiesmedical conditions: Please list any additional medication that the patient is taking: Name: Date: Text15: Check Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffText20: Text21: Text23: Dropdown24: []Dropdown25: []Text37: Text38: Text39: Strength: Dosage Form: QTY per item: Number of item: Other: Addtl # of Refills: compounded med: Text40:


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