**Pet Meds Order Sheet - CanUSAMeds.com**
Step 1:
Step 2:		 Complete this entire form.

Please fax or mail your completed form along with a copy of your ORIGINAL PET 
PRESCRIPTION(s) to:
CanUSAMeds.com
3108 S. Rt. 59
Suite 124-287
Naperville, IL. 60564		 -or- Fax to:
1-866-469-7171
Pet Information Form
Pet Information:
Name of Pet:
Species (i.e. dog, cat, bird)     Breed (if known)
Age of Pet:      Sex (M/F):      Weight:
Allergies (if any):
Prescription Here:
Please Attach Prescription to the Box Below Before Sending:
Attach Additional Sheets if necessary.
Attach Here!
Owner Contact Information:
Owner's Name:     Birthdate:
Telephone:     E-mail:
Mailing Address:
City:
State:
Zip:
Veterinarian Information:
Last Name:     First Name:
Telephone:     Fax:
Mailing Address:
City:
State:
Zip:
Credit Card Information & Authorization:
Cardholder's Name:
Type of Card:      Expiry Date:   
Visa or MasterCard Only
Credit Card Number:
I, authorize CanUSAmeds to apply all applicable charges including the
mailing cost of $9.99 U.S. Dollars to my credit card.
Printed Name of Pet Owner:
Signature of Pet Owner: