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

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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.

Please Choose an Option From the Following See example 1 See example 2(*)

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Please choose the direction of your prescription (*)

Landscape (Wide) Portrait (Tall)

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

1 2 4

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Please Choose(*)

1 Part 2 Part Paper

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Loose sheets or pads of 50.(*)

Pads of 50 sets Loose sheets

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

Yes No

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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(*)

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License Number(*)

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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(*)

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

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

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

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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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