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Veterinarians_Custom Formulation Request

Custom Formulation Request Form

Is there a compound that you want prepared by Akina Pharmacy? Simply fill out this form and our Research and Development team will get to work!

We prepare thousands of products that may not be found in our catalog, and we have extensive resources to meet your needs. Simply fill out the Custom Formulation Request Form below and our Research and Development Team will start digging in to your request!


Custom Formulation Request Form

Prescriber Information

    • Prescriber Name*
    • Email*
    • Practice Name
    • Specialty
  • Key Contact
    • Phone Number*
      Ext
    • Fax Number
  • Address*

Medication Request Information

Please fill out each field with as much detail as you can provide so that we can help you as best as we can!

  • Drug Name(s)*
  • Dosage Strengths(s)*
    • Dosage Form *
    • If other, please specify
    • Route of Administration*
    • If other, please specify
    • Package Size*
    • Directions For Use
    • Order Quantity
  • Order Frequency
  • Additional Information
  • Species