pom-vpsupload - Pet Med Direct

Pom-VPS

Mandatory Information Required

Orders containing POM-VPS products will not be processed unless the form below is completed in full.

If the required information is not provided, your order will be cancelled and a £5 administration charge will be deducted.

Keeper / Owner details

Name

First

Last

Please provide an email address for the invoice

Phone

Enter your phone number incase we need to contact you about your order

Full Address of Animal

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Delivery Address if different

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

I confirm the details provided are accurate and relate to the animals being treated.

I Confirm

the understand Email

I understand a VET or RQP may contact me for more information before supply.

I Confirm

About your pet

Animal Species

eg. Dog, Cat, Rabbit, Horse

Breed / Type

Age

Estimated Animal Weight

Please let us know the estimated animal weight ?

Number of Animals to be treated

Have you used this (or similar) product before?

Purpose of treatment

What are you treating with this product?

Legal Confirmation

I confirm I have read and understood the product directions and that this medicine is for my own animal(s).

I Agree
I Do Not Agree

Please tick this box to confirm that you have read and understood the directions for use of this product. By doing so, you acknowledge that the medicine is being purchased for your own animal(s) and that you will follow all instructions provided on the packaging and product information leaflet. This helps ensure the product is used safely and effectively, in line with the Veterinary Medicines Directorate (VMD) guidelines.

Pom-VPS

Keeper / Owner details

About your pet

Legal Confirmation

Any other information ?

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