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Veterinarians_Prescription-Referral Form.jpg

Prescription Referral Form

We've made prescribing easy to save you and your staff time!

From here you can:

Download the fillable prescription form, complete all of the appropriate information, fax it to Akina Animal Health and we will take it from there

Complete and submit the online form below. We will contact the Pet Parent and take it from there!

This section is for prescribers only.

Prescription forms can only be completed and transmitted by the prescriber.

Patient Information

* Patient Name and Species

* Date of Birth
* Pet Parent Name (Last, First)

* Email
* Phone

* Fax
* Address

Address line 2
* City

* State
* Zip

Diagnosis
* Allergies

Prescription Information

* Medication Name, Strength, and Dosage Form

Flavor
* Quantity

Refills
Medication Name, Dose/Strength, and Dosage Form

Flavor
Refills

Medication Name, Dose/Strength, and Dosage Form
Quantity

Flavor
Quantity

Refills

Prescriber Information

* Prescriber Name

* Date
Key Contact

License#
* Phone

* Fax
* Address

Address line 2
* City

* State
* Zip

DEA#

Shipping and Billing Information

* Ship To:
- Pet Parent' Home
- Prescriber’s Office
- Pick-up
* Bill To:
- Pet Parent
- Prescriber’s Office

ReCheck Reminder ADVOCATING PREVENTATIVE MEDICINE AND IMPROVING OUTCOMES

Please provide the date you would like the patient to return to your clinic for a recheck (mm/dd/yy)

Akina Animal Health will kindly send an email notification reminding the pet parent to make an appointment with your office for a recheck.

Please remember to provide a pet parent email address. This information will never be shared or used for advertising purposes. We promise.

Faxed prescriptions will only be accepted by a prescribing practitioner or a prescribing practitioners authorized agent. All faxed prescriptions must be received directly from the practitioner’s location.

Prescribers are reminded that pet parents may select any pharmacy for their prescription needs.

* Required Fields

Once we receive the completed referral form we will:

Notify the Pet Parent that we have received the prescription and provide an update of the status
We will discuss the medication(s) with the pet parent, any possible side effects, and how to contact Akina Animal Health with questions
We will coordinate for shipping directly to the pet parent or arrange for pick up upon request
Our KiND Care Coordinators partner with you and the pet parent throughout the course of therapy to increase compliance, monitor side effects, and ensure access to all needed resources

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Copyright 2021 Akina Animal Health

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Zip Code *

Telephone Number *

Fax Number *

License Number *

DEA Number

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