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 Heartguard Plus: ________________________________ Veterinarian's Signature Fax this completed form to 818-865-9362