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This prescription is for ANIMAL USE ONLY
1. Prescribing veterinarian
Name
Practice name
Address
Contact details
Signature
Date
2. Restricted Veterinary Medicine/Prescription Medicine
Name
Strength
Quantity to be dispensed on each occasion
Instruction:
Dose
Frequency of dose
Administration site
Period of treatment
Number of repeat supplies
Precautions
3. Owner (owner’s agent) of animal(s)
Name
Address
Contact details
4. Animal(s)
Species
Name