Step 5 of 6:

Create your Official Virtual Petitarian VetX Prescription Form ℹ️ For your protection and security: Your address, telephone number, and fax number will be kept strictly confidential and only Petitarian’s VeX contact information will appear on all your virtual prescription forms to be presented to the fulfilling pharmacy.

Petitarian VetX Prescription

Clinic Name: Petitarian LLC

Vet Name:

License No:

State: California

Address: 30 N Gould Street, Suite R, Sheridan, WY 82801

Phone Number: 1-855-922-4554

Fax Number: 0123456789

DEA License No:

Date

Owner's Name

Client Address

Pet Name Age

Instructions

℞

Medication

Medication Type

Times Per Day

Refill

DR. SIGNATURE: ....................................................................................................................................

Create your Official Virtual Prescription E-Signature (OVPS) below in step 6

Type your Official Virtual Prescription Signature as you would like it to appear on all your Official Virtual Prescription forms issued (OVPS).

KEEP OUT OF CHILDREN’S REACH • FOR VETERINARY USE ONLY

Step 6 of 6:

Create your Official Virtual Prescription E-Signature ℹ️ Type your official virtual prescription signature as you would like it to appear on all your issued virtual official prescriptions.

Type your Official Virtual Prescription Signature as you would like it to appear on all your Official Virtual Prescription forms issued (OVPS).

Type Your Name in the Space Below.
I Agree to Electronic Signing *
CLICK on "SIGN HERE" below to Create, Accept, and Adopt your e-signature to be applied to all your Official Virtual Official Prescription forms (OVPS).

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Change fonts

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

January 27, 2026 9:01 am GMT

Vetx RX Form Uploaded by Justin Dixon - petitarian@petitarian.com IP 207.244.89.162