BIO-SERV
One 8th Street, Suite 1
Frenchtown, NJ 08825
908-996-2155
Medicated Dosing System Request Form
Please PRINT this form, fill it out, and fax to: 908-996-4123
Veterinarian Name _________________________________________________________________
Contact person (if different) ___________________________________________________________
Company/Institution _________________________________________________________________
Street Address _______________________________________________________________________
City _________________________________ State __________ Zip _________________
Phone # _____________________
Fax # _______________________
Email _______________________
Product # ______________
Species to be treated _______________________
Medication Name ____________________________________________________________________
Indications for use ___________________________________________________________________
Dosage desired per 5 gm tablet _________________________________________________________
Instructions for use, including duration ____________________________________________________
Number of medicated tablets ordered _____________________________________________________
each bottle contains 100 tablets
Veterinarian's signature _______________________________________________________________
Date _______________________
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