BBR Heart Worm and Flea Prevention Request Form

If you are a foster parent, please enter your foster code below. Thank you so much for fostering. We couldn't do it without you!

NOTE: EFFECTIVE 12/18/2023 we are transitioning to another veterinary pharmacy provider. During this transition period, we will be unable to fill prescriptions for resident/adopted pups' heartworm and flea prevention medications. We hope to provide this service again within 60 days, and apologize for the inconvenience. If you need financial assistance to cover heartworm and flea medications for your resident/adopted dogs, please go to https://www.bamabully.org/medical-assistance and complete an application.

PLEASE ALLOW AT LEAST ONE MONTH'S LEAD TIME TO FULFILL YOUR REQUEST.

MEDICATION DESCRIPTION: We offer a compounded, monthly, all-in-one heartworm and flea preventive that is comparable to brand name products like Trifexis and Sentinel, but at a fraction of the cost. Like the brand name products, this medication also protects against intestinal parasites, such as roundworms, hookworms, and whipworms. Please note - This formula does not kill adult fleas, but will disrupt the flea's life cycle so that it cannot reproduce. If your pup already has fleas, please discuss immediate flea remedies with your veterinatian. This medication does not protect against tick bites. We require you to seek your veterinarian's advice on whether this is the best medication for your pet(s).

SIX MONTH SUPPLY: Compounded medications have a shorter shelf life than some brand name medications. Therefore, we can send you a six-month supply. Please reorder a refill at least one month in advance.

Owner / Foster Information

First Name *

Last Name *

Email Address *

Cell Phone *

Home Address *

City *

State *

Zip *

Dog(s) Information

Enter each foster dog's name, current weight in pounds, and age in years:

	Dog's Name	Weight in lbs	Age in Years
#1	Dog's Name	Weight in lbs	Age in Years
#2	Dog's Name	Weight in lbs	Age in Years
#3	Dog's Name	Weight in lbs	Age in Years
#4	Dog's Name	Weight in lbs	Age in Years
#5	Dog's Name	Weight in lbs	Age in Years

Total # Dogs: *

Total Due at Checkout (no charge for foster dogs) 🛈

$0.00

Veterinarian's Information

Name of Veterinary Practice *

Street Address

City *

State *

Zip Code

Phone Number *

Please answer each of the following questions:

1. All dogs listed above are up to date on required vaccinations. *

Yes

No

2. All dogs listed above live with me in my home. *

Yes

No

3. I have consulted my veterinarian about the safety of administering the requested medication to my dog(s). *

Yes

No

4. I hereby release, discharge, and hold harmless BBR and any person, firm, or corporation charged or chargeable with liability, their heirs, administrators, executors, successors, and assigns, from any and all claims, damages, costs, expenses, loss of services, actions, and causes of actions, whether known or unknown, belonging to the me due to use of this medication. *

Yes

No

If you answered NO to any of the questions listed above, please explain.

Please proceed to payment. We will verify your information, and process your request as quickly as possible. The medication will be mailed to you at the address provided above. If there is a problem, we will contact you for additional information, and will refund your donation if we cannot fulfill your request for medication.