SECURE CALIFORNIA PRESCRIPTION FORMS

Size: px

Start display at page:

Download "SECURE CALIFORNIA PRESCRIPTION FORMS"

Ralph Gyles Stevens
6 years ago
Views:

1 SECURE CALIFORNIA PRESCRIPTION FORMS HB Fast Print is an approved Security Printer and can provide these forms in both single part & duplicate. CALIFORNIA APPROVED SECURE RX PADS CONTAIN ALL OF THE REQUIRED SECURITY FEATURES, INCLUDING: Script Size: 5-1/2 x 4-1/4 1 Part and 2 Part Forms Available Hidden VOID Message Technology Distinctive BLUE Colored Background Blue Background Erasure Protection Chemical Reactive Security Paper Secure Rub Color Change Ink Hidden Fibers Secure Control Batch Number Security Watermark Security Feature Warning Band Sequential Numbering SINGLE PAGE Rx FORMS #Rx Forms Singles # Pads 100 $ $ $ ,000 $ ,000 $ ,000 $ ,000 $ ,000 $ #Rx Forms Duplicates Optional - Add for wrap-around pads of 50 forms ,000 2,000 3,000 4,000 5,000 $89.00 $99.00 $ $ $ $ $ $ * Padded in sets of 100 forms. CARBONLESS DUPLICATE Rx FORMS * Padded in sets of 50 forms. $ pads $ pads $ pads $ pads $ pads $ pads $ pads $ pads Prices listed do not include sales tax or delivery and are subject to change. Normal turnaround time is about one week 2 day rush orders are available for an additional charge We also provide 8.5 x 11 Rx Laser sheets and custom sizes Please see our standard layouts & indicate what version you would like Layout A Layout B Custom (Additional charges apply) Since Beach Blvd., Suite 24 Huntington Beach, CA Ph: (714) Fax: (714)

2 New order Reorder - No Changes Reorder - With Changes Beach Blvd., Suite 24 Huntington Beach, CA Ph: (714) Fax: (714) California Secure Prescription Form Order Please print a copy of this California Prescription Pad Order Form. After completing all of the information, send your order by FAX or with a copy of your DEA Certificate to. Fax: (714) Note: We screen diligently for fraudulent orders. VERY IMPORTANT ~~~ This is a State requirement. The Department of Justice requires that a copy of your DEA Certificate be sent to us, even on repeat orders. We cannot process any order for which we do not have a current DEA Certificate on file. Once we receive your DEA Certificate, it will be reviewed along with this order form. After it has been determined that everything is in compliance, your order will be processed. Person Entering Order: Order Date: Daytime Phone (include Area Code): Evening Phone (include Area Code): We will send you a proof on all first time orders. Please indicate if you would like to have your proof sent by or fax. For reorders please fax a copy of the Rx along with a copy of the DEA certificate and credit card form. q q Fax Number: Shipping information: THE FORMS MUST BE SHIPPED TO THE ADDRESS ON THE DEA CERTIFICATE OR STATE LICENSE - NO EXCEPTIONS When your order is shipped, a signature will be required when the package is delivered. q SHIP TO ADDRESS -Or- q I WILL PICK UP WHEN COMPLETE Practice Name: Attn: Street Address (No P.O. Boxes Please): Address: City: State: Zip:

3 IMPRINTING INFORMATION for upper portion of Prescription Please fill in the information that needs to be imprinted on the top of each Rx. Un-imprinted forms are not available. Note: We can imprint a combined total of up to nine prescribers and/or addresses. Include DEA# and License # for each doctor listed. A copy of the DEA Certificate for each doctor listed must be sent to us by FAX / along with this order form. We will typeset your information on our standard layout for no charge. If you would like your logo added or a custom layout please fax or a copy with your order. A nominal first time typesetting fee will apply. Address: City: State Zip Code: Mark Box if Applicable All Prescribers on same Rx Separate Rx for each Prescriber Beach Blvd., Suite 24 Huntington Beach, CA Ph: (714) Fax: (714)

4 A 0001 DEA # XXXXXXXXXXXX LIC # XXXXXXX JOHN SMITH, M.D BEACH BLVD., SUITE 24 HUNTINGTON BEACH, CA TEL: (714) FAX: (714) HBFP-XXXXXXXXXX THIS DOCUMENT CONTAINS VOID PANTOGRAPH, ANTICOPY WATERMARK, ERASURE PROTECTION, SECURITY BACKPRINT, THERMOCHROMATIC INK FEATURE, BATCH NUMBERS, CONSECUTIVE NUMBERING, PRINTED ON SAFETY PAPER Male Name D.O.B. Female Address Date Rx Refill NR Void After Do Not Substitute-Dispense As Written SP 72 (714) NON-NEGOTIABLE and over Units Signature Prescription is void if the number of drugs prescribed is not noted DEA # XXXXXXXXXXXX LIC # XXXXXXX JOHN SMITH, M.D BEACH BLVD., SUITE 24 HUNTINGTON BEACH, CA TEL: (714) FAX: (714) B THIS DOCUMENT CONTAINS VOID PANTOGRAPH, ANTICOPY WATERMARK, ERASURE PROTECTION, SECURITY BACKPRINT, THERMOCHROMATIC INK FEATURE, BATCH NUMBERS, CONSECUTIVE NUMBERING, PRINTED ON SAFETY PAPER Male Name D.O.B. Female Rx HBFP-XXXXXXXXXX Address NON-NEGOTIABLE X Date SP 72 (714) Prescription is void if the number of drugs prescribed is not noted.

5 Credit Card Payment Information We accept Visa, Mastercard, Discover and American Express Credit Card Number: Exp. Date (MM/YY) Security Code: (Am/Ex is 4 digits on the front side) Name: (As it appears on the card) Credit Card Billing Address: City, State: Zip Code: B each B lvd., S uite 24 Huntington B each, C A Ph: (714) Fax : (714) E m ail: print@ hbfas tprint.com

CA SECURITY RX FORM PRICE LIST

CA SECURITY RX FORM PRICE LIST December 2005 Only forms available with counterfeit-proof, true-watermark security paper in addition to all required security features to protect your patients, your pharmacists,