Importation Request Form

Veterinarian Information

Licensed veterinarian details and practice information.

First Name *

First name is required.

Last Name *

Last name is required.

Credentials *

Credentials are required.

Email Address *

Valid email is required.

Phone Number *

Phone number is required.

Country *

Country is required.

License State / Province *

License state / province is required.

Country name *

Country is required.

License Number *

License number is required.

Practice / Institution *

Practice name is required.

EIN

Practice/institution EIN (required for Customs documentation).

Patient Information

Details about the animal patient and diagnosis.

Request Type *

Named Patient Pharmacy Shelf Request

Choose Named Patient for a specific animal, or Pharmacy Shelf Request to stock medication without a specific patient.

Pet Owner Name

Animal Name *

Animal name is required.

Species *

Species is required.

Breed

If 'Other', please specify

Age

Weight

Description

Diagnosis & History

Diagnosis *

Diagnosis is required.

Brief Treatment History *

Treatment history is required.

Treatment / Drug Information

Details about the requested treatment or medication.

Drug Name *

Drug name is required.

Drug Name (specify) *

Active Ingredient

NDC Number

Indication

Strength

Intended Use *

Intended use is required.

Quantity *

No greater than a 90-day supply. No refills.

Quantity is required.

Dosage *

Dosage is required.

Route of Administration *

Route of administration is required.

Please specify route *

Please specify the route.

Additional Treatment Notes *

Treatment notes are required.

Warnings and Precautions *

Warnings are required.

Justification for Requested Treatment *

Justification is required.

Delivery & Documents

Shipping address and supporting documentation.

Delivery Address

Product must be shipped to your veterinary practice. Do not list a personal address.

Address Line 1 *

Address is required.

Address Line 2

Country *

Country is required.

State / Province *

State / province is required.

Country name *

Country is required.

City *

City is required.

ZIP / Postal Code *

ZIP / postal code is required.

Document Uploads

If you prefer, you can email documents as PDFs to [email protected]. Max file size: 10 MB.

Copy of License

Click or drag to upload license document

Accepted: PDF, JPG, PNG, DOC, DOCX

Practice Logo

Click or drag to upload practice logo

Accepted: PNG, JPG, SVG, WebP — Minimum resolution: 500 × 500 px

W9

Click or drag to upload W9 document

Accepted: PDF, JPG, PNG, DOC, DOCX

Final Questions

A few last questions before we review your submission.

How did you hear about us? *

Referral Social Media Conference / Convention

Which conference / convention?

Internet Search Listserv / Professional forum Returning customer / Reorder Foundation / Org partnership Other

Please select at least one option.

Referral name / Foundation / Other detail

I consent to receive marketing emails from VMD Sciences.

I have read and agree to VMD Sciences' Terms and Conditions *

You must agree to the Terms and Conditions.

Review & Submit

Please review your information below before submitting.

Importation Request Form

Veterinarian Information

Patient Information

Treatment / Drug Information

Delivery & Documents

Final Questions

Review & Submit

Submission Complete