Select Books or PADS:    

(Once you fill out - click the submit button bottom of form)

Security features : Void Pantograph, Blue Background, Rx Thermochromic Ink, Microprinting in Signature Line, Chemical Protection Paper, Preprinted Prescriber Information, License and DEA Numbers, Format and Size Requirements, California Security Watermark, Reverse Rx, Batch and Sequential Numbering. Each new order includes a proof - within 5 days

 

Use the "TAB" key to move around between boxes

 Clinic or Business Name:

*Prescriber Name:

Specialty:         

Address:              Suite:

City:  State: Zip Code:

Phone #:    

License #:          DEA#:

       NPI#:

 

FOR  CA,  FL, IN, KY, ME, WV, WY

Is Authorized contact person same as person above?:YES

If NO, (Above) Included Name:

Proof?: YES  or   NO

 

Total Number of Prescribers:

Total Number of Addresses: 

Additional Subscribers:   (2nd)

 Clinic or Business Name:

*Prescriber Name:

Specialty:         

Address:              Suite:

City:  State: Zip Code:

Phone #:    

License #:          DEA#:

       NPI#:

(3rd)

 Clinic or Business Name:

*Prescriber Name:

Specialty:         

Address:              Suite:

City:  State: Zip Code:

Phone #:    

License #:          DEA#:

       NPI#:

 

(4th)

 Clinic or Business Name:

*Prescriber Name:

Specialty:         

Address:              Suite:

City:  State: Zip Code:

Phone #:    

License #:          DEA#:

       NPI#:

(If you need more "Prescriber Names" added - No Problem- just fax copy to us  FAX#503-246-1863

     Click "SUBMIT"