Brookeside Veterinary Hospital Hill's Rx Request

REMEMBER:  If you are not an established patient of Brookeside Veterinary Hospital, we'll need you to furnish us with a copy of your veterinary prescription for the Hill's Prescription Diet products you wish to order OR provide us with your Veterinarian's phone number for us to authorize your order.

Pet's Name   

Your Name    

Ship To Address    

City        State        Zip   

Telephone    E-Mail (REQUIRED)

Your Veterinarian's Telephone Number (if you do not FAX your prescription)

What products would you like shipped?

#1       Bag Size   No of Cans     Price

#2       Bag Size   No of Cans     Price

#3       Bag Size   No of Cans     Price

BILLING INFORMATION

Credit Card    Visa MasterCard Discover AMEX     Expiration Date   

Credit Card No               

Name on Card   

Billing Address    Same as Ship to

City        State        Zip   

If you have any questions, please contact us at: (734) 761-7523