Date: ________________________________ Veterinarian or Clinic Name: _________________________________________ Veterinarians Phone Number: ________________________________________ Veterinarians Fax Number: __________________________________________ Name of Pet Owner: _______________________________________________ Name of Pet(s): ___________________________________________________ Heartgard is for _____ Dog(s)  ____Cat(s) Order Code:  44856      Authorization for refill of Heartgard Plus: ________________________________                            Veterinarian's Signature Fax this completed form to 818-865-9362