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Neighbourhood Pet Clinic Auto-Order Parasite Prevention Form
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Name
*
First
Last
Email
*
Delivery Address
*
Address Line 1
Address Line 2
City
--- Select state ---
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State
Zip Code
Name of your furry family member:
*
Species:
*
Dog
Cat
Requested Product(s):
*
Nexgard/Nexgard Spectra
Simparica/Simparica Trio
Other (please specify)
Unsure
If Other, please specify:
*
Requested Product(s):
Nexgard Combo
Revolution Plus
Other (please specify)
Unsure
If Other, please specify:
Duration
*
Ongoing (recommended, as fleas and ticks are active year-round)
Until November of this year (end of heartworm risk)
Other
Please note you can cancel or edit your recurring delivery at any time.
If Other, please specify:
*
Do you have another pet to add?
*
Yes
No
Name of your furry family member:
*
Species:
*
Dog
Cat
Requested Product(s):
*
Nexgard/Nexgard Spectra
Simparica/Simparica Trio
Other (please specify)
Unsure
If Other, please specify:
*
Requested Product(s):
Revolution Plus
Other (please specify)
Unsure
If Other, please specify:
*
Duration
*
Ongoing (recommended, as fleas and ticks are active year-round)
Until November of this year (end of heartworm risk)
Other
Please note you can cancel or edit your recurring delivery at any time.
If Other, please specify:
*
Do you have another pet to add?
*
Yes
No
Name of your furry family member:
*
Species:
*
Dog
Cat
Requested Product(s):
*
Nexgard/Nexgard Spectra
Simparica/Simparica Trio
Other (please specify)
Unsure
If Other, please specify:
*
please and furry
Requested Product(s):
Revolution Plus
Other (please specify)
Unsure
If Other, please specify:
*
Duration
*
Ongoing (recommended, as fleas and ticks are active year-round)
Until November of this year (end of heartworm risk)
Other
Please note you can cancel or edit your recurring delivery at any time.
If Other, please specify:
*
After submitting the form, a team member will review the file and contact you to confirm your prescription has been authorized by a veterinarian and to collect your payment information over the phone. What is the best phone number for us to call to make these arrangements with you?
*
I understand that the month-to-month prevention service is offered as a courtesy by Neighbourhood Pet Clinic. However, all prescriptions, including parasite prevention, are at the discretion of the veterinarian. As such, Neighbourhood Pet Clinic has the right to refuse or adjust a prescription refill request at any time.
*
I have read and understand
Submit
Independently & Locally-Owned
Independently & Locally-Owned