Media Veterinary Hospital

Pet's Name   

Your Name   

Your Address   

City        State        Zip   

Telephone     Evenings

E-mail *Required

Name of Medication   

Dosage (mg., etc.)        No of tablets/capsules, etc.

Is this a refill?    Yes    No

Comments or Questions for the Veterinarian:

Charge to which Credit Card?    Visa MasterCard Discover     Expiration Date   

Credit Card No:               

Name on Card   

Billing Address   

City        State        Zip   

Please Note:  All prescription requests MUST be authorized by the Veterinarian. 

Your credit card statement will be charged to VIRTUAL CLINICS.

Please allow 5 - 7 days for delivery.  For questions, contact (610) 566-1936