123 Prescription Pads RUB RED IMAGE FADES WITH HEAT BLUE BACKGROUND. SECURITY FEATURES LISTED ON BACK Patient Name Date Address WILXXXXXXXX PPXXXXX LABEL Refill Times PRN NR TO INSURE BRAND NAME DISPENSING, PRESCRIBER MUST WRITE "MEDICALLY NECESSARY" ON THE PRESCRIPTION. M.D. PHYSICIAN’S NAME, MD 123 Physicians Way Anytown, U.S.A. 12345 000-000-0000 DEA # or DEA # ___________ NONACUTE PAIN ACUTE PAIN EXCEPTION Secure Prescription 1-Part Pad Pricing 100 Sheets Per Pad (no numbering upcharge) 8 16 24 32 40 64 80 $107.32 $153.62 $235.78 $314.37 $310.41 $446.99 $516.47 Item Number Parts Size QTY DXP1-C3-1-NS24 1-Part non #’d 51/2"W x 41/4"H 100/Pad A. DXP1-C4-1-NS24 1-Part non #’d 41/4"W x 51/2"H DXP2-C3-1-NS24 2-Part non #’d 51/2"W x 41/4"H 50 Sets/Book DXP2-C4-1-NS24 2-Part non #’d 41/4"W x 51/2"H Standard Secure Blue Prescription (includes numbering upcharge) 8 16 24* 32* 40* 64* 80* 240* $166.83 $219.53 $262.57 $343.81 $342.49 $486.99 $561.75 $1,627.71 1-part batch numbering; order in multiples of 4. 1-part consecutive numbering; order in multiples of 8. No upcharge for batch numbering. No charge for consecutive numbering when state mandated. (See non-numbered price.) * 24+ pads add $16.00 flat charge to above pricing Secure Prescription 2-Part Book Pricing 50 Sheets Per Book (no numbering upcharge) 9 18 27 36 81 117 162 252 $118.41 $265.70 $315.18 $345.34 $514.90 $699.31 $936.18 $1,393.86 Item Number Parts Size QTY B. DXP1-C1-1-NS24 1-Part non #’d 51/2"W x 41/4"H 100/Pad DXP1-C2-1-NS24 1-Part non #’d 41/4"W x 51/2"H DXP2-C1-1-NS24 2-Part non #’d 51/2"W x 41/4"H 50 Sets/Book DXP2-C2-1-NS24 2-Part non #’d 41/4"W x 51/2"H Standard Secure Green Prescription (includes numbering upcharge) 9 18 27 36 81 117 162 252 $174.90 $284.12 $340.14 $371.50 $557.69 $757.26 $1,008.40 $1,506.20 2-part; order in multiples of 9. No upcharge for batch numbering. RUB RED IMAGE FADES WITH HEAT GREEN BACKGROUND. REFLECTIVE WATERMARK ON BACK. SECURITY FEATURES LISTED ON BACK. PPXXXXX PHYSICIAN’S NAME, MD 123 Physicians Way Anytown, U.S.A. 12345 000-000-0000 DEA # or DEA # ___________ Patient Name Date Address LABEL Refill Times PRN NR TO INSURE BRAND NAME DISPENSING, PRESCRIBER MUST WRITE "MEDICALLY NECESSARY" ON THE PRESCRIPTION. WIL000000000 NONACUTE PAIN ACUTE PAIN EXCEPTION Security Features • Chemical Protection Paper, Scallop Void Pantograph, Blue or Green Background, Security Watermark on Back, Preprinted Prescriber Information, Rx Thermochromic Ink, Microprinting in Border Line, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid Compliant. (R) Production time: 5 working days. (R) Production time: 5 working days. Standard RX Pads cannot be used in all states, please check your state guidelines before purchasing. Checks & Forms Popular Industries Veterinary Optometry Ophthalmology Scan here to see how our security features keep your prescription paper safe from fraud B. A.
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