Medicine BottleAquia-Garrisonville Animal Hospital
Medication Order Form
*must be a current client


Is this order for:
Shipping/Delivery (pay at time of order)        
Pickup at our Hospital   (pay at time of pickup)

Owner's Name:

Pet's Name (one per form):

Home Telephone Number:

Street Address:     Apt#

City:

State: Zip Code:  


(Please fill out payment information only if needing your order shipped)

Payment Method:

Card Number:           Exp. Date:  Month:  Year
 

Medication Request (Check all that apply):

HeatWorm Control/Prevention Products:
Heartworm Supply: 6 months 12 months









Heartgard: 
Blue, 0-25 lbs
Green, 26-50 lbs Brown, 51-100 lbs

Tri-Heart: 0-25 lbs
 26-50 lbs
 51-100 lbs

Interceptor: Brown, 2-10 lbs Yellow, 11-25 lbs
 Green, 26-50 lbs
 White, 51-100 lbs
Sentinel: Brown, 2-10 lbs
 Yellow, 11-25 lbs
 Green, 26-50 lbs
 White, 51-100 lbs

Flea/Tick Control Products:
Frontline Plus Supply 3 months 6 months


Frontline Plus: Feline 0-22 lbs (Canine) 23-43 lbs (Canine) 44-88 lbs (Canine) 89-132 lbs (Canine)
Revolution for Cats
 6 pack



Capstar (6 pack): 2-25 lbs


Other Prescription Orders or Information:
(*$3.00 S/H for orders not containing any of the above)