15DC2770_Clinical Forms_173-196 2/13/15 10:32 AM Page 184 Laser Prescription Forms CLINICAL FORMS A B Compatib le with C Compatib le with F Compatib le with le with Compatib le with le with Compatib M Compatib le with I Compatib L E Compatib H K Compatib le with G Compatib J D le with N le with STATE-APPROVED LASER PRESCRIPTIONÂ BLANK FORMS * Forms comply with the most current individual state regulations * All papers meet "tamper-resistant" Medicaid requirements effective October 2008 * Paper size: 81/2"W x 11"H H. Indiana Full Sheet with Detachable Top-Left Script (367-5294) ....................................................................................500 per Pkg. 2 Pkg.@ A. Alaska Full Sheet with Detachable Top-Left Script (367-5867) ....................................................................................500 per Pkg. 2 Pkg.@ 69.99 65.99 B. Delaware Full Sheet (368-0184) ..................................................................................1000 per Pkg. 2 Pkg.@ 199.99 189.99 C. Florida Full Sheet (367-7818) ..................................................................................1000 per Pkg. 2 Pkg.@ 219.99 209.99 D. Florida Full Sheet with Detachable Top-Left Script (367-7821) ..................................................................................1000 per Pkg. 2 Pkg.@ 219.99 209.99 E. Florida 1/2 Perforated Sheet (367-7819) ..................................................................................1000 per Pkg. 2 Pkg.@ 219.99 209.99 F. Florida 1/4 Perforated Sheet (367-7820) ..................................................................................1000 per Pkg. 2 Pkg.@ 219.99 209.99 G. Georgia Full Sheet (367-7862) ..................................................................................1000 per Pkg. 2 Pkg.@ 99.99 94.99 184 www.henryscheindental.com 474.99 449.99 I. Kentucky Full Sheet with Detachable Top-Left Script (367-5861) ....................................................................................500 per Pkg. 2 Pkg.@ 129.99 119.99 J. Maine Full Sheet with Detachable Top-Left Script (367-5296) ....................................................................................500 per Pkg. 2 Pkg.@ 159.99 149.99 K. Washington State Full Sheet (367-7298) ....................................................................................500 per Pkg. 2 Pkg.@ 84.99 80.99 L. Washington State Full Sheet with Detachable Top-Left Script (367-7300) ....................................................................................500 per Pkg. 69.99 M. Washington State 1/2 Perforated Sheet (367-7295) ....................................................................................500 per Pkg. 2 Pkg.@ 84.99 80.99 N. Washington State 1/4 Perforated Sheet (367-7299) ....................................................................................500 per Pkg. 2 Pkg.@ 69.99 65.99 * All products featured here are NOT for use in other states.http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675294%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675867%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675861%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3680184%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675296%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677818%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677298%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677821%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677300%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677819%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677295%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677820%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677299%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677862%26CatalogName%3DDENTAL http://www.henryscheindental.com