POM-VPS or NFA-VPS Form

Name

Email Address

Telephone

What is the species being treated? Cattle – BeefCattle – DairySheepMultiple SpeciesOTHER

If you selected 'Other' or 'Multiple species' please list what species here

How many animals are being treated?

What are the approximate weight (kg) / size of the animals to be treated?

Have any of the animals to be treated had an adverse reaction? NoYes

If you replied 'Yes' to the question above, please note product & type of reaction

What product was used last to treat this condition?

Are you confident to be administering this product? YesNo

Will you follow the manufacturer's instructions? YesNo

Are all the animals kept at the order delivery address? YesNo

If no, please state where are the animals kept?