California Compliant Prescription Pads

Name: California Compliant Prescription Pads
SKU: 0-2-1-1-1-1-1-1-1-1-2
Availability: InStock

Price

$150.00 – $760.00 Plus Tax

Number of Compliant Pads

Production Time (From Proof Approval to Boxed and Ready to Ship)

Custom Artwork Need - IE incorporating your company’s logo or branding elements - $95 additional

Clear

State

Clinic Name

Text Alignment*

Center

Left

Type of paper

Single Ply (100 sheets per pad)

Two Ply Carbonless (50 sheets per pad)

Number of Prescriptions On the Sheet*

Number of Prescribers*

Number of Addresses*

First Address

Address Displayed on Pad*

City*

Zip*

State*

NOTE - If the shipping address for these pads is different than the address on record associated with the DEA #, then one of our representatives will reach out to you to finalize your order.

Telephone Number (no parentheses or dashes)*

Fax

Second Address

Address Displayed on Pad

City

Zip

State

Telephone Number (no parentheses or dashes)

Fax

Third Address

Address Displayed on Pad

City

Zip

State

Telephone Number (no parentheses or dashes)

Fax

First Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Second Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Third Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Fourth Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Fifth Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Sixth Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Seventh Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Eight Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Ninth Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Tenth Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Eleven Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

Twelve Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

Prescriber Name

Category of Licensure (MD, DDS, PA etc…)

State License Number

NPI #

DISCLAIMER - By checking this box, this is not a validation that enables the writing of these prescriptions.

Proof*

I Accept The Proof

I Accept Proof but I Would Like to Make Minor Changes

I would like to request a proof be emailed to me

This will have a delay on your order.

Please briefly describe the changes

SKU: 0-2-1-1-1-1-1-1-1-1-2 Category: Uncategorized

California Compliant Prescription Pads

Price

First Address

NOTE - If the shipping address for these pads is different than the address on record associated with the DEA #, then one of our representatives will reach out to you to finalize your order.

Second Address

Third Address

First Prescriber

Second Prescriber

Third Prescriber

Fourth Prescriber

Fifth Prescriber

Sixth Prescriber

Seventh Prescriber

Eight Prescriber

Ninth Prescriber

Tenth Prescriber

Eleven Prescriber

Twelve Prescriber

DISCLAIMER - By checking this box, this is not a validation that enables the writing of these prescriptions.

This will have a delay on your order.

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Additional information

Orignal Data

Number of Compliant Pads	60 Compliant Pads $595, 40 Compliant Pads $430, 24 Compliant Pads $295, 12 Compliant Pads $180, 8 Compliant Pads $150
Production Time (From Proof Approval to Boxed and Ready to Ship)	Next Day Turnaround – $75 Additional, Standard 5-7 Days
Custom Artwork Need - IE incorporating your company’s logo or branding elements - $95 additional	Add Custom Artwork – $95, No Additional Custom Artwork

California Compliant Prescription Pads

Price

First Address

NOTE - If the shipping address for these pads is different than the address on record associated with the DEA #, then one of our representatives will reach out to you to finalize your order.

Second Address

Third Address

First Prescriber

Second Prescriber

Third Prescriber

Fourth Prescriber

Fifth Prescriber

Sixth Prescriber

Seventh Prescriber

Eight Prescriber

Ninth Prescriber

Tenth Prescriber

Eleven Prescriber

Twelve Prescriber

DISCLAIMER - By checking this box, this is not a validation that enables the writing of these prescriptions.

This will have a delay on your order.

Live Preview

Convas test

Additional information

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Orignal Data

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California Compliant Prescription Pads