Prescription Pads

Non-secure RX pads

Size: 4.25" x 5.5"
Paper: RX pads
Ink: Blue & Black

Non Secure

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.)

$69.00

No. of Pads	No. of Scripts	Price Per Pad	Total Price
4	100	17.25	69.00
8	100	12.38	99.00

Prescription Pads

Prescription Pads

Non Secure

To begin your order, complete this form.

Pricing Matrix

PLEASE CHOOSE YOUR LOCATION

california

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