prescription pad order form - irp-cdn.multiscreensite.com€¦ · please print a copy of this...
TRANSCRIPT
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.
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: _____________________________________________________________________________________
Best Number to call (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 email or fax. For reorders please email or FAX a copy of the Rx along with a copy of the DEA certificate and credit card form.
E-mail: _______________________________________ Fax Number: _______________________________Shipping information:
THE FORMS MUST BE SHIPPED TO THE ADDRESS ON THE DEA CERTIFICATE OR STATE LICENSE - NO EXCEPTIONSWhen your order is shipped, a signature will be required when the package is delivered.
“SHIP TO
* If I am not present to sign for the order when it is delivered I authorize _________________________________________
to sign and accept delivery on my behalf *Authorizing Prescriber-Print Name ____________________________________________
ADDRESS” (FILL IN BELOW) -Or-(PLEASE MAKE SURE ADDRESS MEETS ABOVE REQUIREMENTS) (FOR ESTABLISHED CLIENTS ONLY)
“TO BE PICKED UP WHEN COMPLETE” BY LISTED PRESCRIBER ONLY
Practice Name: ( If applicable) _____________________________________________________________________
Attn: ________________________________________________________________________________
Street Address (No P.O. Boxes Please): ______________________________________________________________
City: ___________________________________________State: _______________ Zip: ______________________
New OrderReorder - No Changes Reorder - With Changes Rush + $60 Ships in 2-3 Days
www.hbfastprintinc.com
17610 Beach Blvd., Suite 24 • Huntington Beach, CA 92647 • Ph: (714) 848-0015 • Fax: (714) 375-6596 Email: [email protected]
California Secure Prescription Form OrderPlease print a copy of this California Prescription Pad Order Form.
After completing all of the information, send your order by email or FAX with a copy of your DEA Certificate to:
Email: [email protected] Fax: (714) 375-6596
IMPRINTING INFORMATION for upper portion of PrescriptionPlease 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 eight prescribers and/or addresses. Include DEA and License number for each prescriber listed. A copy of the DEA Certificate for each prescriber listed must be sent to us by FAX / email 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 email a copy with your order. A nominal first time typesetting fee will apply.
Facility Name (if applicable)__________________________________________________________________________________________Name (Include Designation-ie: MD, DDS)______________________________________________________________________________ DEA# ___________________________State Lic.#________________________N.P.I. # (If applicable)____________________________ Address: __________________________________________________________________________________________________________ City: ______________________________ State _____________ Zip Code: ____________________________________________________ Telephone:____________________________________Fax:_________________________________________________________________
Facility Name (if applicable)__________________________________________________________________________________________Name (Include Designation-ie: MD, DDS)______________________________________________________________________________ DEA# ___________________________State Lic.#________________________N.P.I. # (If applicable)____________________________ Address: __________________________________________________________________________________________________________ City: ______________________________ State _____________ Zip Code: ____________________________________________________ Telephone:____________________________________Fax:________________________________________________________________
Facility Name (if applicable)__________________________________________________________________________________________Name (Include Designation-ie: MD, DDS)______________________________________________________________________________ DEA# ___________________________State Lic.#________________________N.P.I. # (If applicable)____________________________ Address: __________________________________________________________________________________________________________ City: ______________________________ State _____________ Zip Code: ____________________________________________________ Telephone:____________________________________Fax:_________________________________________________________________
Facility Name (if applicable)__________________________________________________________________________________________Name (Include Designation-ie: MD, DDS)______________________________________________________________________________ DEA# ___________________________State Lic.#________________________N.P.I. # (If applicable)____________________________ Address: __________________________________________________________________________________________________________ City: ______________________________ State _____________ Zip Code: ____________________________________________________ Telephone:____________________________________Fax:_________________________________________________________________
Facility Name (if applicable)__________________________________________________________________________________________Name (Include Designation-ie: MD, DDS)______________________________________________________________________________ DEA# ___________________________State Lic.#________________________N.P.I. # (If applicable)____________________________ Address: __________________________________________________________________________________________________________ City: ______________________________ State _____________ Zip Code: ____________________________________________________ Telephone:____________________________________Fax:_________________________________________________________________
*Mark Box if Applicable All Prescribers on same Rx
www.hbfastprintinc.com17610 Beach Blvd., Suite 24 • Huntington Beach, CA 92647 • Ph: (714) 848-0015 • Fax: (714) 375-6596 • Email: [email protected]
Separate Rx for each Prescriber
A
B
SECURE CALIFORNIA PRESCRIPTION FORMS
#Rx Forms Duplicates Optional - Add for wrap-around pads of 50 forms
• Barcoded Serial Numbers • Hidden “VOID” Pantograph • Distinctive BLUE Colored Background • Erasure ProtectionChemical Reactive Security Paper • Control Batch Number • Anticopy Watermark • Sequential Numbering
• Heat Sensitive Ink Feature • Feature Printed in Opaque Ink • Security Features Warning Band
* Padded in sets of 50 forms.
Prices listed do not include sales tax or delivery and are subject to change.
Normal turnaround time is approximately 5-7 business days before shipping Rush orders are available for an additional $60 charge
Please see our standard layouts & indicate what version you would like
CARBONLESS DUPLICATE Rx FORMS 4.25 x 5.5
www.hbfastprintinc.com17610 Beach Blvd., Suite 24 • Huntington Beach, CA 92647 • Ph: (714) 848-0015 • Fax: (714) 375-6596
Email: [email protected]
Layout A Layout B Custom (Additional charges apply)
Since 1975
#Rx Forms Singles # Pads
100 $79.00 1
200 $99.00 2
400 $119.00 4
1,000 $149.00 10
2,000 $269.00 20
3,000 $379.00 30
4,000 $489.00 40
5,00
100 200 400 1,000 2,000 3,000 4,000 5,000
$119.00 $139.00 $159.00 $249.00 $389.00 $529.00 $669.00 $799.00
- 2 pads$10.00 $10.00 - 4 pads$15.00 - 8 pads$20.00 - 20 pads$40.00 - 40 pads$60.00 - 60 pads$80.00 - 80 pads$100.00 - 100 pads
0 $599.00 50
SINGLE PART Rx FORMS 4.25 X 5.5
* Padded in sets of 100 forms.
#Rx Forms Singles
+ INITIAL SET UPCHARGE
FOR CUSTOMLAYOUTS
WILL VARY
*LOOSE SHEETS- NOT PADDED
100 $129.00200 $199.00400 $269.001,000 $399.002,000 $599.00
SINGLE PART Rx FORMS 8.5 X 11
WE ARE COMPLIANT TO PRINT BARCODED SERIALIZED RX FORMS, PER ASSEMBLY BILL AB-149, EFFECTIVE JANUARY 1, 2020. CALIFORNIA APPROVED SECURE RX FORMS CONTAIN ALL OF THE REQUIRED SECURITY FEATURES, INCLUDING:
Exp. Date (MM/YY) Security Code: (Am/Ex is 4 digits on the front side)
Credit Card Payment InformationWe accept Visa, Mastercard, Discover and American Express
Credit Card Number:
Name:
Credit Card Billing Address:
City, State:
Zip Code:
* We do not keep credit card information on fileThis information is shredded immediately after processing
(As it appears on the card)
www.hbfastprintinc.com17610 Beach Blvd., Suite 24 • Huntington Beach, CA 92647 • Ph: (714) 848-0015 • Fax: (714) 375-6596
Email: [email protected]