Non Secure Pads

Name: Non Secure Pads
SKU: 0-2-1-1-1-1-1-1-1-1-2-2-1-1-1
Availability: InStock

DISCLAIMER – Please note, non-secure prescription pads are not valid for controlled substance prescriptions. If you need secure pads, please go back and select Minimum Security or Maximum Security pads.

Price

$55.00 – $415.00 Plus Tax

Do You Want to Add Your Logo?

Production Time

Number of Compliant Pads

Clear

State

Type of paper*

Single Ply (100 sheets per pad)

Two Ply Carbonless (50 sheets per pad)

Number of Prescribers*

Number of Addresses*

First Address

Practice Name

Address Displayed on Pad*

City*

State*

Zip*

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

Practice Name

Address Displayed on Pad

City

State

Zip

Telephone Number (no parentheses or dashes)

Fax

Third Address

Practice Name

Address Displayed on Pad

City

State

Zip

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?

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

Prescriber Name

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

Specialty

State License Number

NPI #

Second Prescriber

DEA #

Prescriber Name:

Address on Record:

City:

State:

Zip:

Do you want to include an XDEA Number?

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

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?

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

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?

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

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?

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

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?

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

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.

You must Preview before you accept the proof. I accept the proof.

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

Please briefly describe what you are looking for

Check this box if you do not want to display DEA number(s) on this pad. Note that by checking this box it will apply to all DEA numbers on this form

Hide DEA

Select Which Color Form You Want*

Non Secure Pads quantity

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

Add to Cart

Live Preview

The image on the screen may not accurately represent your state’s pad, however, your pads are 100% guaranteed to be compliant with your state’s guidelines.

prescriber selection problem v3 (non secure)

Canvas main programing v3 ( Non Secure )

Description
Additional information

Additional information

Do You Want to Add Your Logo?	No, Yes, Add Logo – Additional $25
Production Time	Standard 5 Business Days, Next Day Turnaround ($95 Extra )
Number of Compliant Pads	16 Compliant Pads $85, 24 Compliant Pads $125, 40 Compliant Pads $195, 8 Compliant Pads $55, 80 Compliant Pads $295

here nothing

DEA:
Prescriber Name:
Address:
City:
State:
Zip:

Orignal Data

Maximum Security Tamper Resistant

$135.00 – $905.00 Plus TaxSelect options This product has multiple variants. The options may be chosen on the product page

Minimum Security State Compliant

$95.00 – $715.00 Plus TaxSelect options This product has multiple variants. The options may be chosen on the product page

Non Secure 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

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

Second Prescriber

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

Third Prescriber

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

Fourth Prescriber

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

Fifth Prescriber

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

Sixth Prescriber

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

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

You must Preview before you accept the proof. I accept the proof.

This will have a delay on your order.

Live Preview

prescriber selection problem v3 (non secure)

Canvas main programing v3 ( Non Secure )

Additional information

Orignal Data

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