15DC2770_Clinical Forms_173-196 2/13/15 10:32 AM Page 181 State-Approved Prescription Blanks We Have Your State-Approved Prescription Forms California, Horizontal New Jersey, Vertical Indiana, Horizontal IMPRINT OPTIONS: Single Doctor/Single Address YOURTOWN CLINIC John Smith, M.D. 123 Your Address Yourtown, USA 00000 (000) 000-0000 Fax (000) 000-0000 * Manufactured with highly specialized, state-mandated security paper and inks * Pricing includes imprinting of all necessary practice and licensing information * Additional charges will apply for the sequential numbering for states where there is no requirement * Additional charges will apply for back printing of forms No. of Parts Size # of Pads 1-Part 2-Part 1-Part 2-Part 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 41⁄4" W x 51⁄2" H 41⁄4" W x 51⁄2" H 1-Part 2-Part CLINICAL FORMS California, Vertical STATE-APPROVED PRESCRIPTION BLANKS Item # Format CALIFORNIA Horizontal 1. 368-0032 368-0033 Horizontal 368-0056 Vertical 368-0057 Vertical DELAWARE 368-0058 Horizontal 368-0059 Horizontal FLORIDA 368-0034 Horizontal 368-0035 Horizontal 368-0049 Vertical 368-0050 Vertical GEORGIA 367-7953 Horizontal 367-7955 Horizontal INDIANA Horizontal 2. 368-0030 368-0031 Horizontal KENTUCKY 368-0040 Horizontal 368-0041 Horizontal MAINE 368-0038 Horizontal 368-0039 Horizontal *NEW JERSEY Vertical 3. 368-1705 368-1706 Vertical WASHINGTON 368-0042 Horizontal 368-0043 Horizontal WEST VIRGINIA 368-0044 Horizontal 368-0045 Horizontal WYOMING 368-0047 Horizontal 368-0048 Horizontal *Imprint style is state mandated 3 2 1 Lic. # DEA # NPI # Multi Doctor/Multi Address Doctor Doctor Doctor Doctor 1 Lic. # 1 DEA 2 Lic. # 2 DEA 3 Lic. # 3 DEA 4 Lic. # 4 DEA 123 Your Address Yourtown, USA 00000 (000) 000-0000 Fax (000) 000-0000 # of Prescriptions per Pad Total # of Prescriptions Price 2@ 50 50 50 50 500 500 500 500 100.79 162.79 95.79 162.79 60.79 102.99 57.79 102.99 43.29 69.99 39.99 79.79 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 10 10 100 50 1000 500 122.99 140.99 82.99 93.79 65.29 70.49 1-Part 2-Part 1-Part 2-Part 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 41⁄4" W x 51⁄2" H 41⁄4" W x 51⁄2" H 10 10 10 10 100 50 100 50 1000 500 1000 500 92.49 134.79 92.49 134.79 64.29 86.29 64.29 86.29 43.29 65.29 43.29 65.29 1-Part 2-Part 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 10 10 100 50 1000 500 85.29 125.99 56.79 81.79 49.49 60.99 1-Part 2-Part 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 10 10 100 50 1000 500 89.29 100.99 70.49 70.49 60.99 53.79 1-Part 2-Part 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 10 10 100 50 1000 500 84.29 126.29 56.79 80.99 49.49 60.99 1-Part 2-Part 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 10 10 100 50 1000 500 105.29 153.29 71.49 98.79 54.79 70.49 1-Part 2-Part 4" W x 51⁄2" H 4" W x 51⁄2" H 10 10 100 50 1000 500 117.99 167.99 88.99 99.99 64.99 78.99 1-Part 2-Part 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 10 10 100 50 1000 500 100.99 152.29 67.29 97.79 52.79 70.49 1-Part 2-Part 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 10 10 100 50 1000 500 84.29 126.29 56.79 81.99 49.49 60.99 1-Part 2-Part 51⁄2" W x 41⁄4" H 51⁄2" W x 41⁄4" H 10 10 100 50 1000 500 84.29 133.79 57.99 123.79 1 2 3 4 4@ 10 10 10 10 # # # # 43.29 95.29 For imprinted Materials Call 1-800-414-0940 8am-4:30pm (et) Prescription Blanks continued on next page. 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