COUNTRYSIDE MOBILE VET

ORDER FORM

FREE SHIPPING!

Name:

Date:

Phone:

Shipping Address:

Pet’s Name(s):

HEARTGARD PLUS (6 PACKS) QUANTITY

BLUE (under 25 lbs) $30.00 ___________ Refills of other medications may

GREEN (25-50 lbs) $40.00 ___________ be available by mail. Call with

BROWN (51-100 lbs) $48.00 ___________ any questions.

FRONTLINE PLUS (3 PACKS)

SMALL DOG (under 22 lbs) $47.00 ___________ **IMPORTANT**

MEDIUM DOG (23-44 lbs) $48.00 ___________ We must have seen your animal

LARGE DOG (45-88 lbs) $52.00 ___________ before we can send out any

EX. LARGE DOG (89-132 lbs) $53.00 ___________ medication.

CAT $46.00 ___________ MAIL OR CALL:

Countryside Animal Clinic

REVOLUTION (CATS) P.O. Box 356

SMALL (<5 lbs) 3 pack $48.00 ___________ N. Zulch, TX 77872

REGULAR (5.1-15 lbs) (936) 399-6017

3 pack $48.00 ___________ (713) 492-8045

6 pack $85.00 ___________

COMFORTIS (flea pill for Dogs only)

5 lbs- 10 lbs 3 mo $53.00 _______ 6 mo $93.00 _______

10.1 lbs- 20 lbs 3 mo $54.00 _______ 6 mo $94.00 _______

20.1 lbs- 40 lbs 3 mo $55.00 _______ 6 mo $95.00 _______

40.1 lbs- 60 lbs 3 mo $56.00 _______ 6 mo $96.00 _______

60.1 lbs- 120 lbs 3 mo $57.00 _______ 6 mo $97.00 _______

CIRCLE METHOD OF PAYMENT (DO NOT SEND CASH)

CHECK (Include DL# on check) or MONEY ORDER ENCLOSED

VISA MASTERCARD DISCOVER

CARD # ___________________________ expiration__________

Last 3 digits of code on rear of card ______ bill mailing zip______

Signature____________________________________________

WE DO NOT AUTHORIZE ANY INTERNET PHARMACY Rx.