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Prescription Referral Form

Akina Animal Health Prescription Referral Form

We’ve made prescribing easy to save you and your staff time. From here you can:

Number1  Download the fillable prescription form, complete all of the appropriate information, fax it to Akina Animal Health and we will take it from there

Number2  Complete and submit the online form below. We will contact you to confirm receipt of the order and to verify the details of the prescription order.

This section is for prescribers only.

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

Number1  Prescription Referral Form by Fax
      Click the button below to download the Prescription Referral Form.

  Prescription Referral Form Online
      Complete the form below with as much detail as possible and submit.

Patient Information

Prescription Information

Prescriber Information

Shipping and Billing Information


  • 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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