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Compliant Prescription Pads

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

Price

$235.00 – $965.00 Plus Tax

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

Number of Compliant Pads

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

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

Compliant Prescription Pads quantity

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

Checkout

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.

california

Description
Additional information

Additional information

Custom Artwork Need - IE incorporating your company’s logo or branding elements - $95 additional	Add Custom Artwork – $95, No Additional Custom Artwork
Number of Compliant Pads	12 Compliant Pads – $270, 24 Compliant Pads – $375, 40 Compliant Pads – $525, 8 Compliant Pads – $235, 80 Compliant Pads – $795
Production Time (From Proof Approval to Boxed and Ready to Ship)	Rush 5 Business Days +$75, Standard 8-10 Business Days

Orignal Data

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