Practice Marketing & Office Supply Catalog 2015 - 182

15DC2770_Clinical Forms_173-196 2/13/15 10:32 AM Page 182

Prescription Blanks

PREVENT FRAUD!
CLINICAL FORMS

We Have the Level of Security Features You Require
A

VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID

Security Prescription
VOID VOID Blank
VOID VOID
VOID Security Prescription Blank
VOIDJOHN SMITH, M.D.
VOID VOID VOID VOID VOID
VOID JOHN SMITH, M.D.
VOID VOID VOID VOID VOID VOID
VOID
VOID VOID VOID VOID VOID VOID
VOID
VOID VOID VOID VOID VOID VOID
VOID
VOID VOID VOID VOID VOID VOID
VOID
VOID VOID VOID VOID VOID VOID
8 SECURITY FEATURES
VOID
VOID VOID VOID VOID VOID VOID
VOID
VOID VOID VOID VOID VOID VOID
VOID
VOID VOID VOID VOID VOID VOID
VOID
VOID VOID VOID VOID VOID VOID
VOID VOID VOID
Premium, Horizontal
VOID VOID VOID
(1, 2, 3, 4, 5, 6, 7, 8)
VOID VOID VOID
VOID VOID VOID
123 YOUR ADDRESS
YOURTOWN, USA 00000
(000) 000-0000
Fax (000) 000-0000

LIC# 00000
DEA # BA0000000

123 YOUR ADDRESS
YOURTOWN, USA 00000
(000) 000-0000
Fax (000) 000-0000

SECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECUR

PATIENT _____________________________________________________________________________

, M.D.
SMITH
JOHN Your Address 00
000
123

B

WN, USA
YOURTO ) 000-0000
0
(000
) 000-000
Fax (000
________

________

________

________

NAME

________

________

S
ADDRES

E
____ DAT

________

________

AGE ____

JOHN SMITH, M.D.

____

________

123 Your Address
YOURTOWN, USA 00000
(000) 000-0000
Fax (000) 000-0000

__

________

________

________

Name ______________________________________________________________________________________
Address ______________________________________________________________ Date__________________

LIC# 00000
DEA # BA0000000

D.O.B. __________________________

ADDRESS ____________________________________________________________________________

DATE ___________________________

SECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITY

Touch Rx symbol, color will disappear then reappear.

PRE-BOND

VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID

PATIENT _________________________________________________________

D.O.B. __________________

ADDRESS ________________________________________________________

DATE ___________________

Touch Rx symbol, color will disappear then reappear.

Security Features. Details on back.

PRE-BOND

Security Features. Details on back.

NO SECURITY

Refill NR 1 2 3 4 5
Void After _________________________
_________________________
Signature
Prescription is void if more than one (1) controlled substance is written per blank.

Do Not Substitute-Dispense As Written

________

LABEL
REFILL

________

________

________

__M.D.

S

__TIME

________

JOHN SMITH, M.D.
123 Your Address
YOURTOWN, USA 00000
(000) 000-0000

C

JOHN SMITH, M.D.
Specialty
123 Your Address
Yourtown, USA 00000
(000) 000-0000
Fax (000) 000-0000

THIS DOCUMENT CONTAINS VOID PANTOGRAPH, MICROPRINTED SIGN. LINE, REVERSE RX AND SECURITY BACKPRINT

Name ________________________________________________________

THIS DOCUMENT CONTAINS VOID PANTOGRAPH, MICROPRINTED SIGN. LINE, REVERSE RX AND SECURITY BACKPRINT

Address ____________________________________ Date ____________

Name ____________________________________________________________________________

Premium, Vertical

PRESCRIPTION PADS

Address ________________________________________ Date ____________________________

8 SECURITY FEATURES

(1, 2, 3, 4, 5, 6, 7, 8)

Protective security features include:

Refill NR 1 2 3 4 5 Void after __________________________

SECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTION

1. Chemically Reactive Paper-Changes color to indicate
exposure to chemical solvents, oxidants, acids, or alkalis

M.D.

SECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTION

Dispense as Written

May Substitute

M.D.

Refill NR 1 2 3 4 5 Void after __________________________

Prescription is void if more than one (1) prescription is written per blank.
SECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTI

M.D.

SECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONSECUREDPRESCRIPTIONS

Dispense as Written

M.D.

May Substitute

Prescription is void if more than one (1) prescription is written per blank.

The word "VOID" appears in a continuous pattern when photocopied.

2. Heat-sensing Imprint-Disappears when touched
3. Invisible Fluorescent Fibers-Appear only under black light

JOHN

4. Void Pantograph-The word "VOID" appears when
blanks are scanned or photocopied
5. Microprint Safety Line-Appears as a solid rule, but
reads "Security Prescription" when magnified
6. Reverse Rx-Disappears if background color is lightened

D

JOHN SMITH, M.D.
123 Your Address
YOURTOWN, USA 00000
(000) 000-0000
Fax (000) 000-0000

SM

123 You ITH, M.D.
YOURTO r Address
WN,
(000) 000 USA 00000
Fax (000 -0000
) 000-000
0

NAME

________

________

ADDRES

________

________

S ____
____

________

________

________

________

____ DAT
E

________

________

AGE ____

____

________

__

Name ____________________________________________________________________________
Address ________________________________________ Date ____________________________

3 SECURITY FEATURES
(1, 3, 5)

7. Security Features List-The back of the blank lists security features to
help deter fraudulent activity and to help officials determine authenticity

Name ___________________
Refill NR 1 2 3 4 5
Prescription is void if more than one (1) prescription is written per blank.

LABEL

Address _________________
REFILL
____
______T

IMES
________

8. "Security Prescription" Background-The words "Security Prescription"
appear as a continuous pattern across the back of the blank

________

________

________

__M.D.

Woven background that exposes erasures and alterations

# of
# of Prescriptions
Total #
of Prescriptions Price
2@
Item #
Format
No. of Parts
Size
Paper Color Pads
per Pad
A. PREMIUM SECURITY PADS: The most secure available! Copy-proof, chemical-evident paper, with temperature-sensitive imprinting (Exceeds Medicaid Requirements).
368-0025
Horizontal
1-Part
51⁄2" W x 41⁄4" H
G
10
100
1000
96.79 70.49
368-0054
Vertical
1-Part
41⁄4" W x 51⁄2" H
G
10
100
1000
86.79 70.49
B. REGULAR Rx PADS: Available in 1-Part or 2-Part format with canary copy. Signature line can be added as per individual state law requirements.
368-0026
Horizontal
1-Part
51⁄2" W x 41⁄4" H
W, B, C, G, P 10
100
1000
75.79 52.79
368-0051
Vertical
1-Part
41⁄4" W x 51⁄2" H
W, B, C, G, P 10
100
1000
75.79 52.79
368-0027
Horizontal
2-Part
51⁄2" W x 41⁄4" H
W
10
50
500
135.49 79.99
368-0052
Vertical
2-Part
41⁄4" W x 51⁄2" H
W
10
50
500
135.49 79.99
C. HIGH-SECURITY Rx PADS: Special paper stock shows an unmistakable pattern if photocopied (Exceeds Medicaid Requirements).
1
1
W
10
100
1000
81.99 56.79
368-0028
Horizontal
1-Part
5 ⁄2" W x 4 ⁄4" H
368-0053
Vertical
1-Part
41⁄4" W x 51⁄2" H
W
10
100
1000
81.99 56.79
368-0188
Horizontal
2-Part
51⁄2" W x 41⁄4" H
W
10
50
500
130.49 72.79
368-0189
Vertical
2-Part
41⁄4" W x 51⁄2" H
W
10
50
500
130.49 72.79
D. SAFETY Rx PADS: Feature tamper-resistant blue-woven background to expose erasures or alterations.
368-0029
Horizontal
1-Part
51⁄2" W x 41⁄4" H
Blue Safety
10
100
1000
90.49 65.29
368-0055
Vertical
1-Part
41⁄4" W x 51⁄2" H
Blue Safety
10
100
1000
90.49 65.29
368-0190
Horizontal
2-Part
51⁄2" W x 41⁄4" H
Blue Safety
10
50
500
139.79 107.29
368-0191
Vertical
2-Part
41⁄4" W x 51⁄2" H
Blue Safety
10
50
500
139.79 107.29

Step

1

Choose PAPER

182

Blue
(B)

Canary
(C)

2

Green
(G)

www.henryscheindental.com

Pink
(P)

56.79
56.79
37.99
37.99
61.99
61.99
38.99
38.99
52.79
52.79
49.49
49.49
76.79
76.79

Choose DESIGN

Single Doctor/Single Address
YOURTOWN CLINIC

(Only applies to Regular Rx Pads (1-Part)

White
(W)

Step

4@

John Smith, M.D.
123 Your Address
Yourtown, USA 00000
(000) 000-0000
Fax (000) 000-0000

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

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Practice Marketing & Office Supply Catalog 2015

Table of Contents for the Digital Edition of Practice Marketing & Office Supply Catalog 2015
