Importation Request Form

If you are seeking a treatment that is currently unlicensed in your country, we have the experience to help. Please fill out the required fields below in detail. VMD Sciences’ team of Regulatory Experts will support you in navigating your country’s regulatory requirements. If approved, VMD will support fulfillment of your prescription.

Please let us know if you have any questions or need additional support by contacting us at connect@vmdsciences.com.

*If your animal is experiencing a medical emergency or you feel their condition can/should not wait to receive medical attention, please contact your veterinarian or local Emergency Veterinary Hospital immediately.

Licensed Veterinarian Name

First Name

Last Name

Practice Email Address

Practice Phone Number

(###)

###

####

Practice Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

License Number

License State

Animal Name

Species

If 'Other' Please List Below

Age

Weight

Description

Breed, Coloring, Defining Features, etc.

Pet Owner Name

First Name

Last Name

Diagnosis

Brief Treatment History

Summary of treatments patient has undergone for this condition, dates, and outcomes.

Drug Name

Intended Use

Strength

Quantity

No greater than a 90-day supply based on your practice's needs. No refills.

Expiration

Dosage Instructions

Additional Treatment Notes

Protocol, Administration Method, or other important details.

Warnings and Precautions

Justification for Requested Treatment

Why is this the best option for treatment? Are there other animals that may be affected if left untreated? etc.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about us?

Referral

Social Media

Conference/Convention

Internet Search

Other

Refferal Name/Other

Importation Request Form

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