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Get Ia Revival Animal Health Prescription Authorization Fax Form 2016-2025

Working with Revival Animal Health for the fulfillment of your client s pet prescription needs. You are receiving this form because of the customer listed below. If you would like to speak with one of our pharmacists or call in your prescription, please call 712-737-5555 x134. We would be glad to assist you. PET OWNER - please print your information below OWNER First Name Last Name Customer # (optional) ADDRESS City State PHONE EMAIL PATIENT S NAME SPECIES MALE/FEMALE DATE OF BI.

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