POM-VPS Form

The product you are ordering is a Prescription Only Medicine (eg. vaccine, fly and worm control products).
To enable us to prescribe this for you please could you complete the questionnaire below.
Unfortunately we are unable to process your order without the completion of this form.
If you are experiencing any difficulties please contact us on 01425 474455

Product Required

Your Email

Your Name

Are you the registered keeper/owner of the animal(s) to be treated?

Yes

If you replied 'No' to the above, please supply the name and address of the registered keeper

What is the species of the animal being treated? Please select

Sheep

Cattle

Pigs

Goats

Cats

Dogs

Poultry

Will the animal be intended for any of the following food use (please tick all that apply)

Select allClear choices

Meat

Milk

Eggs

Flock/Herd Number (Required Field)

Holding Number (Required Field)

Number of animals to be treated

What is the weight of animals to be treated?

Why is this product required? Please select

Following vet advice

Following results from a egg count or antigen test

Following a diagnosis (please specify below)

Part of my health plan

Historic risk on farm

Prevention of disease (fly control/vaccination)

Other

Please give details of any diagnosis you have been given,

If you replied "other" to the above, why do you require this product?

Please provide any further information you may have to help us prescribe your medicine?

Have you used this product before?

Yes

Are the animals in good health?

Yes

If "no", please give details

Is the animal pregnant or lacatating

Clear choice

Yes

If applicable how many days until calving

What product did you use last time and when?

Have any of the animals to be treated ever suffered an adverse reaction?

Yes

Please acknowledge you will read the data sheet before administration and are aware of the appropriate safety precautions

Yes

Would you like a phone call from an SQP to discuss safe administration of this product or for any further advice?

If yes, please enter Phone Number below

Yes

Phone Number