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

Reference

* 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 to be responsible for the accuracy and completeness of the provided information and to possess any information that might be missing from the prescription form.

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Prescription form

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