Prescription Pads

50 Security forms per pad. Size of pad: 4" x 5" Exceeds California Department of Justice Security Printer Program & SB151 security requirements. Up to five prescribers and/or locations may be included in the imprint area at top of form. Second part transfers the information you write (patient name, DOB, medication prescribed, etc.) from the top copy. No other printing on part two. Refer to the price list for current pricing and ordering increments.

Size: 4" x 5"
Paper: Rx Security Script
Ink: Blue & Black

Two-Part Standard-Size Pads - Up to 3 Medications

You may order pads in any quantity, for pricing refer to pricing matrix

To begin your order, complete this form.

All items marked with an asterisk * are required.

1 *Enter Quantity (No. of pads you want to order)

2 Name of Your Medical Practice (if any) 3 *Include Name of Medical Practice on Script?

Yes No

4 Type of Medical Practice (Specialty) 5 *Include Type of Medical Practice on Script?

Yes No

6 *Designated Physician/prescriber -- More than one prescriber? Complete field #19 below

(include your medical designation -- i.e. M.D., D.D.S., D.V.M., NP, etc.)

7 *Address -- More than one location? Complete field #21 below

8 *Zip 9 *City

10 *State 11 *Phone Number

12 Fax Number 13 Fax number on scripts?

Include fax # on your scripts Do not include fax # on your scripts

14 *License Number

15 *Federal Controlled Substance/DEA No.
(It should begin with 2 capital letters followed by 7 digits. Example: AA1234567) 16 We are required to have a DEA Registration for each prescriber on file prior to order shipment. You may:

Attach and send via website Fax to 661-481-3630

17 Attach DEA Registration: 18 *Total Number of Prescribers Imprinted

19 Additional Prescriber Information

(For additional prescribers, please include Name, License Number, and Federal Controlled Substance/DEA No. One prescriber (the name you entered in field #6 above) is included in the base price. Additional prescribers are $9.75 each. If you're adding additional prescribers be sure and adjust the number of prescribers accordingly in field #18)

20 *Total Number of Locations Imprinted

for additional prescribers, please include Name, License Number, and Federal Controlled Substance/DEA No.)

21 Additional Location Information

(For additional locations, please provide: Address, City, State, Zip Code, telephone number and fax number -- if you want that included -- for each location. One location (as entered in fields #7-10 above) is included in the base price. Additional locations are $9.75 each. If you're adding additional locations be sure and adjust the number of locations accordingly in field #20)

22 *Email

for additional prescribers, please include Name, License Number, and Federal Controlled Substance/DEA No.)

$87.95

Two-Part Standard Size (4 x 5)
50-Scripts Per Pad - Part Two Blank
No. of Pads	No. of Scripts	Price Per Pad	Total Price
1	50	87.95	87.95
4	200	39.75	159.00
8	400	24.20	193.60
10	500	21.30	213.00
20	1000	18.05	361.00
40	2000	15.85	634.00
50	2500	15.75	787.00
60	3000	15.50	930.00
80	4000	14.95	1,196.00

Prescription Pads

Prescription Pads

Two-Part Standard-Size Pads - Up to 3 Medications

To begin your order, complete this form.

Pricing Matrix

PLEASE CHOOSE YOUR LOCATION

california

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