Vendor Medication Request Form

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?*

Select

What is the medication name?*

Select the most applicable category*

Select

Is this product being replaced?

Select or enter value

Drug Class

Sales Unit of Measure (UOM)

List Cost*

Offer Price*

MSRP

MAP

Dosage Form

Strengths

Route of Administration

Select or enter value

Is dilution needed?

Select or enter value

Special handling precautions

ex. wear gloves

Order Routing

Select or enter value

Contraindications

File Upload*

Please include:

- Safety Data Sheet

- Product Insert Sheet

- Veterinarian Letter (showcasing indications)

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

- FAQ sheet

Drag and drop files here or

Send me a copy of my responses