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Template RX Pad

Date:

*

Client Name:

*

Pet Name:

*

Primary phone number:

*

Address:

*

DOB:

*

Patient Species:

*

Sex:

*

https://storage.tally.so/bce88421-7092-40c4-b62f-db517b409422/Screenshot-2025-10-22-at-12.05.03-PM.png

Untitled checkboxes field

Dispense as written

*

Substitution Permitted

Doctor Signature:

*

Signature

Signature Date

*

Dr.

*

LIC #

*