Prescription Pads
A.
WILXXXXXXXX
PHYSICIAN’S NAME, MD 123 Physicians Way Anytown, U.S.A. 12345 000-000-0000 DEA # or DEA # ___________ NONACUTE PAIN ACUTE PAIN EXCEPTION
Patient Name
Address
Date
B.
WIL000000000
PHYSICIAN’S NAME, MD 123 Physicians Way Anytown, U.S.A. 12345 000-000-0000 DEA # or DEA # ___________
NONACUTE PAIN ACUTE PAIN EXCEPTION
Popular Industries Veterinary Optometry Ophthalmology
Patient Name
Address
Date
LABEL
Refill
Times PRN NR
RUB RED IMAGE
TO INSURE BRAND NAME DISPENSING, PRESCRIBER MUST WRITE "MEDICALLY NECESSARY" ON THE PRESCRIPTION. M.D.
FADES WITH HEAT
BLUE BACKGROUND. SECURITY FEATURES LISTED ON BACK
LABEL
Refill
Times PRN NR
RUB RED IMAGE
GREEN BACKGROUND. REFLECTIVE WATERMARK ON BACK. SECURITY FEATURES LISTED ON BACK. TO INSURE BRAND NAME DISPENSING, PRESCRIBER MUST WRITE "MEDICALLY NECESSARY" ON THE PRESCRIPTION.
FADES WITH HEAT
Standard RX Pads cannot be used in all states, please check your state guidelines before purchasing.
Security Features • Chemical Protection Paper, Scallop Void Pantograph, Blue or Green Background, Security Watermark on Back, Preprinted Prescriber Information, Rx Thermochromic Ink, Microprinting in Border Line, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid Compliant.
Standard Secure Blue Prescription
Standard Secure Green Prescription
Item Number
Parts
Size
QTY
Item Number
Parts
Size
QTY
DXP1-C3-1-NS24 1-Part non #’d 51/2"W x 41/4"H
B. DXP1-C1-1-NS24
1-Part non #’d 51/2"W x 41/4"H 1-Part non #’d 41/4"W x 51/2"H 2-Part non #’d 51/2"W x 41/4"H
100/Pad
100/Pad
A. DXP1-C4-1-NS24 1-Part non #’d 41/4"W x 51/2"H DXP2-C3-1-NS24 2-Part non #’d 51/2"W x 41/4"H DXP2-C4-1-NS24 2-Part non #’d 41/4"W x 51/2"H
DXP1-C2-1-NS24 DXP2-C1-1-NS24
50 Sets/Book
50 Sets/Book
DXP2-C2-1-NS24 2-Part non #’d 41/4"W x 51/2"H
Secure Prescription 1-Part Pad Pricing 100 Sheets Per Pad (no numbering upcharge)
Secure Prescription 2-Part Book Pricing 50 Sheets Per Book (no numbering upcharge)
8
16
24
32
40
64
80
9
18
27
36
81
117 162
252
$107.32
$153.62
$235.78
$314.37
$310.41
$446.99
$516.47
$118.41 $265.70
$315.18 $345.34 $514.90
$699.31
$936.18 $1,393.86
(includes numbering upcharge)
(includes numbering upcharge)
8
16 24*
32*
40*
64*
80*
240*
9
18
27 36
81
117
162
252
$166.83
$219.53 $262.57
$343.81 $342.49 $486.99
$561.75
$1,627.71
$174.90
$284.12
$340.14 $371.50 $557.69 $757.26 $1,008.40 $1,506.20
(R) Production time: 5 working days.
2-part; order in multiples of 9. No upcharge for batch numbering. (R) Production time: 5 working days.
1-part batch numbering; order in multiples of 4. 1-part consecutive numbering; order in multiples of 8. No upcharge for batch numbering. No charge for consecutive numbering when state mandated. (See non-numbered price.) * 24+ pads add $16.00 flat charge to above pricing
123
Made with FlippingBook Learn more on our blog