Secure Tamper Resistant Order Form
ADVERTISEMENT
1
2SECURE TAMPER RESISTANT ORDER FORM
Please Print Clearly
Distributor Name __________________________________ Account # ______________________
Address __________________________________________ Phone # ______________________
Contact __________________________________________ Fax # ________________________
City ______________________ ST ______ ZIP ___________ PO# ________________________
Prescriber Information (As you want it to appear on the form)
*Required Field
Clinic or Business Name ___________________________________________________________
*Prescriber Name ________________________________________________________________
Specialty _______________________________________________________________________
*Address __________________________________________ Ste: _________________________
*City __________________________________________ *State _______ Zip ________________
*Phone # _____________________ *License# ___________________ DEA # _______________
(If State Required, Include DEA #)
Fax # _____________________ Starting # ___________________
Total # of Prescribers________
Total # of Addresses________
(Enter Additional Prescribers on Page 2)
Ship To _________________________________
Ship Method
________________________________________
FedEx Ground
FedEx Priority Overnight
________________________________________
FedEx 2nd Day
FedEx Express Saver
________________________________________
Other _____________________________
1 Part Pads
2 Part Sets
Cut Sheets
(100 sheets per pad)
(50 sets per pack)
(100 sheets per set)
4-1/4”w X 5-1/2”h (Vertical)
4-1/4”w X 5-1/2”h (Vertical)
8 1/2”x 11”
(1 script per sheet)
5-1/2”w X 4-1/4”h (Horizontal)
5-1/2”w X 4-1/4”h (Horizontal)
Quantity:
Quantity:
Quantity:
4 pads
4 packs
4 sets
8 pads
8 packs
8 sets
12 pads
12 packs
12 sets
16 pads
16 packs
16 sets
20 pads
20 packs
20 sets
40 pads
40 packs
40 sets
60 pads
60 packs
60 sets
80 pads
80 packs
80 sets
Leadtime: 3-5 Days after order approval
Valid for Medicaid Prescriptions in the following states:
AL, AK, AZ, AR, CO, CT, GA, HI, ID, IL,IA,
KS, LA, MD, MA, MI, MN, MS, MO, MT, NE, NV, NH, NM, NC, ND, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT,
VA, WI
NOT Valid for Medicaid Prescriptions in the following states:
CA, DE, FL, IN, KY, ME, NJ, NY, WA,
WV, WY
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business