Uniform New Jersey Prescription Blanks Order Form Page 2
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1
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3FORM TYPE: Please Check One (Prices subject to change without notice)
1-Part Pads – Single Sided (100 blanks per pad)
NUMBERING IS REQUIRED
q 5 pads
q 10 pads
q 20 pads
q 40 pads
q 50 pads
q 80 pads
q 100 pads
ALL ORDERS SUBJECT TO
$80.00
$93.00
$128.00
$199.00
$235.00
$399.00
$395.00
ADDITIONAL SHIPPING AND
1-Part Pads with Alternate Address – 2 Sided (100 blanks per pad)
HANDLING CHARGES
q 5 pads
q 10 pads
q 20 pads
q 40 pads
q 50 pads
q 80 pads
q 100 pads
$115.00
$135.00
$195.00
$283.00
$330.00
$477.00
$567.00
NJ State law requires barcode
numbering on all RX pads. If you do
2-Part Carbonless Pads (50 blanks per pad)
not provide us your starting number,
q 10 pads
q 20 pads
q 40 pads
q 80 pads
q 100 pads
q 160 pads
q 200 pads
we will use our default starting number
$135.00
$189.00
$260.00
$419.00
$499.00
$680.00
$800.00
which if #001001.
2-Part Carbonless Pads with Alternate Address – 2 Sided (50 blanks per pad)
q 10 pads
q 20 pads
q 40 pads
q 80 pads
q 100 pads
q 160 pads
q 200 pads
State law requires 6 digit numbers.
$189.00
$274.00
$367.00
$590.00
$698.00
$952.00
$1120.00
Any starting number you want can be
used, as long as it has 6 digits. Please
1 Sided Laser Forms on 8.5 x 11 Sheets q TOP LEFT POSITION q CENTER POSITION
provide your starting number below.
q 250 Sheets
q 500 Sheets
q 1000 Sheets
q 2000 Sheets
q 4000 Sheets
q 5000 Sheets
$108.00
$155.00
$269.00
$369.00
$599.00
$685.00
Starting #:______________________
Same Day Proof
Same Day Proof-Printing & Shipping
Custom Imprinting Prescription
Add $25.00
Add 50% To Printing Costs
Specific Information or Warnings
This order complies with NJ State Law
Add $35.00
changes as of May 19, 2014
Information to be printed on Prescription Blank:
1. Practice or Facility Name (if to be printed): ____________________________________________________________________________________________
2. Prescriber Name: _______________________________________________________________________________ Degree: _________________________
3. Practice or Specialty (only if to be printed on pads below prescriber name[s]): ________________________________ License # ________________________
Address to be printed on front: ______________________________________________________________________________________________________
_____________________________________________________________________ National Provider Identifier # (NPI #): __________________________
Telephone # to be printed: ________________________________________________ Fax # (if to be printed): _____________________________________
4. Specify if Applicable: Dea # ______________________________________________ TPA Cert # ______________________________________________
(if DEA # is not provided, a blank line will be printed to be filled in by prescriber where applicable.)
(For Opto, must be printed.)
Facility Provider # ___________________________________________________ Certification # _________________________________________________
MUST HAVE EACH TIME ORDER IS PLACED
IMPORTANT: If more than one prescriber is listed on the same blank, one of the
prescribers is to be responsible for the shipment. That person must sign below:
Prescriber
PLEASE NOTE: By signing, you are the responsible party for this shipment of prescription blanks. Please make
Signature: ______________________________________________
certain that the ship to address given below is the same as it appears with your medical licensing board.
OPTIONAL:
Additional doctors to be printed on the same prescription blank (or one collaborating physician if ordering pads for Nurse Practioner/Certified
Nurse Midwife/Physician Assistant):
1. Prescriber Name: _____________________________________________
2. Prescriber Name: _____________________________________________
License #: ____________________ Degree: ________________________
License #: ____________________ Degree: ________________________
DEA # or other info to be printed: _________________________________
DEA # or other info to be printed: _________________________________
*Prescriber Signature: ________________________________________
*Prescriber Signature: ________________________________________
3. Prescriber Name: _____________________________________________
4. Prescriber Name: _____________________________________________
License #: ____________________ Degree: ________________________
License #: ____________________ Degree: ________________________
DEA #: ______________________ NPI #: _________________________
DEA #: ______________________ NPI #: _________________________
*Prescriber Signature: ________________________________________
*Prescriber Signature: ________________________________________
OPTIONAL:
Additional addresses to be printed on the back of prescripion blanks (must include phone number):
If additional addresses are required, attach separate sheet (up to 4 addresses).
Street: ________________________________________________________
Street: ________________________________________________________
City, State, Zip: __________________________________________________
City, State, Zip: __________________________________________________
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)
(
)
Phone: __
_______
_______________________________________________
Phone: __
_______
_______________________________________________
Bill To:
Ship To: (Official address on file with the State Board)
Practice Name __________________________________________________
Practice Name __________________________________________________
Address ________________________________ Room/Suite/Bldg. ________
Address ________________________________ Room/Suite/Bldg. ________
City ___________________________________ State _____ Zip __________
City ___________________________________ State _____ Zip __________
Attention _______________________________ Phone _________________
Attention _______________________________ Phone _________________
Phone: 201.670.9797
Uniform New Jersey Prescription Blanks Order Form
Fax: 201.670.9798
Please print clearly to avoid any mistakes
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Parent category: Medical