Uniform New Jersey Prescription Blanks Order Form printable pdf download

Uniform New Jersey Prescription Blanks Order Form

Please print clearly to avoid any mistakes

CUSTOMER INFORMATION

PRACTICE NAME

STREET ADDRESS (REQUIRED FOR UPS SHIPMENT) CITY, STATE AND ZIP

PHONE NUMBER (INCLUDE AREA CODE)

FAX NUMBER (INCLUDE AREA CODE)

NAME OF PURCHASER

EMAIL ADDRESS

OFFICE CONTACT PERSON

EMAIL ADDRESS

TEL (INCLUDE AREA CODE)

Ordering Instructions:

. Per state requirements, all orders and reorders for Uniform New Jersey Prescription Blanks must be submitted in writing via mail or fax.

2. Use one Order Form per prescription order. Multiple prescriber names and one address may be printed on the front of each prescription.

Additional addresses may be printed on the back for an additional cost.

3. The address used for shipping must match with the listing of authorized prescribers and health care facilities on file with the licensing board.

4. License numbers must be provided for each prescriber facility.

5. The signature of each authorized prescriber or health care facility representative must be provided with each order.

6. Payment via credit card only. Completed credit card form with signature must accompany this order or it will not be processed.

ORDERING INFORMATION: Please Check One

State of New Jersey

PRESCRIPTION BLANK

STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK

LICENSE #

DEA #

LICENSE #

DEA #

AFFILIATED PHYSICIAN

CERTIFICATION #

DEA #

NAME ________________________________________________ LICENSE # ________________________________

LICENSE #

DEA #

LICENSE #

DEA #

COLLABORATING PHYSICIAN

IF PRESCRIPTION IS WRITTEN AT ALTERNATE PRACTICE SITE, CHECK HERE

TELEPHONE # _______________________________

DELEGATED PHYSICIAN SUPERVISOR

AND PRINT ALTERNATE ADDRESS AND TELEPHONE NUMBER ON REVERSE SIDE

NAME

LICENSE #

TEL #

(Enter Address and Phone Number only if different from above)

PATIENT ____________________________________________________________________________________ D.O.B. ___________________

IF PRESCRIPTION IS WRITTEN AT ALTERNATE PRACTICE SITE, CHECK HERE

ADDRESS

AND PRINT ALTERNATE ADDRESS AND TELEPHONE NUMBER ON REVERSE SIDE

PHONE #

ADDRESS __________________________________________________________________________________ DATE ___________________

PATIENT ______________________________________________________________________ D.O.B.

_______________

NOT VALID FOR SCHEDULE II CONTROLLED SUBSTANCES. VALID FOR TOPICAL

ADDRESS ____________________________________________________________________ DATE

_______________

PHARMACEUTICAL AGENTS (IF TPA CERTIFIED) AND PRESCRIPTION EYEWEAR ONLY.

PATIENT

D.O.B.

ADDRESS

DATE

oPRT

oSPD

SUBSTITUTION PERMISSIBLE ____________________________

DO NOT SUBSTITUTE _____________________

SUBSTITUTION PERMISSIBLE ____________________________

DO NOT SUBSTITUTE _____________________

SUBSTITUTION PERMISSIBLE ____________________________

DO NOT SUBSTITUTE _____________________

SUBSTITUTION PERMISSIBLE ____________________________

DO NOT SUBSTITUTE _____________________

SIGNATURE OF PRESCRIBER

DO NOT REFILL _______

REFILL ________ TIMES

Use a separate form for each controlled substance prescription

THEFT, UNAUTHORIZED POSSESSION AND/OR USE OF THIS FORM INCLUDING ALTERATIONS OR FORGERY, ARE CRIMES PUNISHABLE BY LAW

Optometrist

CUSTOM IMPRINT

State of New Jersey

PRESCRIPTION BLANK

State of New Jersey

OR INSTRUCTIONS

PRESCRIPTION BLANK

LICENSE #

PRINT ABOVE

NAME AND TITLE OF PRESCRIBER AND, IF APPLICABLE, COLLABORATIVE PHYSICIAN

LICENSE #

DEA #

PRT

IF PRESCRIPTION IS WRITTEN AT ALTERNATE PRACTICE SITE, CHECK HERE

VALID ONLY FOR PRESCRIPTION EYEWEAR

CHECK IF

APN

CNM

PRESCRIBER

AND PRINT ALTERNATE ADDRESS AND TELEPHONE NUMBER ON REVERSE SIDE

SPD

LICENSE / CERTIFICATE / Rx AUTHORIZATION #

COLLABORATIVE PHYS

PATIENT ____________________________________________________________________________________ D.O.B. ___________________

PATIENT ____________________________________________________________________________________ D.O.B. ____________________

ADDRESS __________________________________________________________________________________ DATE ___________________

ADDRESS __________________________________________________________________________________ DATE _____________________

NOT VALID FOR SCHEDULE II CONTROLLED SUBSTANCES. VALID FOR TOPICAL

SPHERE

CYLINDER

AXIS

PRISM

PHARMACEUTICAL AGENTS (IF TPA CERTIFIED) AND PRESCRIPTION EYEWEAR ONLY.

NOT VALID FOR CONTROLLED SUBSTANCES IF ISSUED BY AN OPTOMETRIST

ADD

P.D. _________ / _________

SUBSTITUTION PERMISSIBLE ____________________________

DO NOT SUBSTITUTE _____________________

ADD

REMARKS:

SIGNATURE OF PRESCRIBER

SUBSTITUTION PERMISSIBLE ____________________________

DO NOT SUBSTITUTE _____________________

DO NOT REFILL _______

SIGNATURE OF PRESCRIBER

DO NOT REFILL _______

REFILL ________ TIMES

SIGNATURE OF PRESCRIBER

DO NOT REFILL _______

REFILL ________ TIMES

Use a separate form for each controlled substance prescription

REFILL ________ TIMES

THEFT, UNAUTHORIZED POSSESSION AND/OR USE OF THIS FORM INCLUDING ALTERATIONS OR FORGERY, ARE CRIMES PUNISHABLE BY LAW

Use a separate form for each controlled substance prescription

THEFT, UNAUTHORIZED POSSESSION AND/OR USE OF THIS FORM INCLUDING ALTERATIONS OR FORGERY, ARE CRIMES PUNISHABLE BY LAW

Uniform New Jersey Prescription Blanks Order Form

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