Order Design

Please type information EXACTLY as you want it to appear on your RX Pads

See Images of 4 1/4 x 5 1/2 Portrait , 5 1/2 x 4 1/4 Landscape , 5 1/2 x 8 1/2 , 8 1/2 x 11

Please Choose Size See Examples (*)

A. 5 1/2" wide by 4 1/4" tall B. 4 1/4" wide by 5 1/2" tall C. 5 1/2" wide by 8 1/2" tall D. Letter size sheets for laser printer Invalid Input

When purchasing laser sheets, no imprint is required by us. You must follow Florida laws when finalizing your imprint.

Your Rx Prescriptions will come in pads of 50. If you want a different amount, please leave a comment in the Special Instructions box.

Invalid Input

Please choose the direction of your prescription (*)

Landscape (Wide) Portrait (Tall) Invalid Input

Choose how many prescriptions per 8.5 in x 11 in sheet(*)

1 2 4 Invalid Input

Please Choose(*)

1 Part 2 Part Paper Invalid Input

Loose sheets or pads of 50.(*)

Pads of 50 sets Loose sheets Invalid Input

Do you want the Rx count verifications on the lower right of the prescription? What will this look like?(*)

Yes No Invalid Input

Practice or Company Name

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Physicians Name(s)(*)

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Number of addresses to appear on your Rx pads

Single address Two or more addresses Invalid Input

Please Enter Address(es) here. (*)

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Phone Number(*)

123-456-7890

Fax Number

123-456-7890

Mobile Phone

123-456-7890

DEA Number(*)

Invalid Input

License Number(*)

Invalid Input

NPI Number

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Choose quantity of pads (50 each) for your 1 part, 5 1/2" by 4 1/4" Rx Pads(*)

Invalid Input

Choose quantity of pads (50 each) for your 2 part, 5 1/2" by 4 1/4" Rx Pads(*)

Invalid Input

Choose quantity of pads (50 each) for your 1 part, 4 1/4" by 5 1/2" Rx Pads(*)

Invalid Input

Choose quantity of pads (50 each) for your 2 part, 4 1/4" by 5 1/2" Rx Pads(*)

Invalid Input

Choose quantity for your 1 part, letter size sheets for laser printer(*)

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Choose quantity for your 2 part, letter size sheets for laser printer(*)

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*Please enter desired quantity in the Special Instructions box

Special Instructions

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