Receptformulier

Prescription form

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Veterinarian *

Veterinary Medicine Register Nº / UDN Nº *

DAP *

Address

Residence

Date

Name of recipient animal keeper

Address of animal keeper

Place of residence of animal keeper

Animal identification

(Probability) diagnosis

Name of veterinary medicinal product + packaging unit *

Units *

Dosage

Duration of Treatment

Passport note excluded from slaughter

Yes No

Waiting time ( concerns the minimum recommended waiting period in days after last treatment (Milk/Meat) )

Signature of prescribing veterinarian / Signature of animal owner / Name and signature for receipt

Any additional information

* By signing this prescription form, the prescribing veterinarian declares that he is aware of the responsibilities arising from European Regulation 2019/6 and Implementing Regulation 2021/963.

* By signing this prescription form, the prescribing veterinarian declares that he is responsible for the accuracy and completeness of the information provided.

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Prescription form

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