Vendor Medication Request Form

NOTE: only MEDICATIONS are accepted for review at this time.

Company & Contact Information

Your Name

Manufacturer Name

Contact Email

Phone Number

Continuing Education (CE) Contact Name

Do you have CE presentations available?

Product Information

What is the medication name?

Select the most applicable category

Is this product being replaced?

Drug Class

Sales Unit of Measure (UOM)

List Cost

Offer Price

MSRP

MAP

Dosage Form

Strengths

Route of Administration

Special handling precautions

ex. wear gloves

Order Routing

Contraindications

File Upload

Please include:

- Safety Data Sheet

- Product Insert Sheet

- Veterinarian Letter (showcasing indications)

- Supporting literature (peer review, studies, etc.)

- FAQ sheet

Drop your files here

Send me a copy of my responses