Micro Format Inc.
www.CaliforniaRxPaper.com ~ www.RxPaper.com
830-3 Seton Court ~ Wheeling IL 60090
Toll Free Order Line: 800-333-0549 ~ Fax:847-520-0197 ~ Local Tel:847-520-4699

California Prescription Pad
FAX ORDER FORM

Micro Format, Inc. is an approved California Pharmacy Board Security Prescription Pad Printer.
Please print a copy of this California Prescription Pad Order Form.
After completing all of the information, send your order by FAX to (847)520-0197
You may also send your order by mail to:
Micro Format, Inc � Customer Service ~ 830-3 Seton Court ~ Wheeling IL 60090

Note: We screen diligently for fraudulent orders.
At Micro Format, printing Security Prescription Paper is our business ... not a side line !

VERY IMPORTANT ~~~
The California State Pharmacy Board requires that a copy of your DEA Registration be sent to us by FAX.

This is a State requirement.
We cannot process any order for which we do not have a current DEA Registration form on file.
Please FAX a copy of your DEA Registration form to
MICRO FORMAT CUSTOMER SERVICE ~ Fax Number: (847)520-0197
Thank you. Once we receive your DEA Registration Certificate, it will be reviewed along with this order form. After it has been determined that everything is in order,
your order will be processed.

PA prescription Authority Documentation

A PA must have their DEA registration AND supervising physician's information on their prescriptions.

California Law requires that a physician assistant authorized to write controlled substance drug orders pursuant to authority granted to them by their supervising physician and DEA registration, must have their supervising physician's name, DEA registration number, address, and telephone number preprinted on the physician assistant's preprinted controlled substance prescription form.

Person Entering Order

Is this your first order? (Yes or No)

If this is a Re-Order ...
Please enter BATCH NUMBER as it appears on your scripts
MFI

Order Date:

Purchase Order Number (optional):

Practice Name:

Physician Name:

Specialty:

Street Address (No P.O. Boxes Please):

Address:

City:

State: Zip:

Daytime Phone (include Area Code):

Evening Phone (include Area Code):

e-mail:

Fax Number:

DEA #

State License # Expiration Date:

IMPORTANT � Please Note
When your order is shipped, a signature will be required when the package is delivered.

SHIP TO ADDRESS (if different than above)

Practice Name:

Physician Name:

Street Address (No P.O. Boxes Please):

Address:

City:

State: Zip:

Choose Script Format and Quantity Needed

Item# Rx710

5-1/2� x 4-1/4� Pads ~ Room to imprint 4 Doctor�s Names or 3 Names plus Facility Name

1 part pads - 100 sheets per pad

20 pads ~ $9.30 per pad plus shipping by UPS

40 pads ~ $7.35 per pad plus shipping by UPS

60 pads ~ $6.85 per pad plus shipping by UPS

80 pads ~ $6.45 per pad plus shipping by UPS

2 part pads - 50 sets per pad (part 1 white security ~ part 2 BLANK yellow copy)
padded with wraparound cover

20 pads ~ $14.90 per pad plus shipping by UPS

40 pads ~ $13.00 per pad plus shipping by UPS

60 pads ~ $12.28 per pad plus shipping by UPS

80 pads ~ $11.85 per pad plus shipping by UPS

Item# Rx720

5� x 7� Pads � Oversize Pads ~ Room to imprint up to 8 Doctor�s Names
1 part pads - 100 sheets per pad

20 pads ~ $14.90 per pad plus shipping by UPS

40 pads ~ $12.50 per pad plus shipping by UPS

60 pads ~ $11.75 per pad plus shipping by UPS

80 pads ~ $11.10 per pad plus shipping by UPS

2 part pads - 50 sets per pad (part1 white security � part 2 BLANK yellow copy)
padded with wraparound cover

20 pads ~ $19.95 per pad plus shipping by UPS

40 pads ~ $16.10 per pad plus shipping by UPS

60 pads ~ $15.50 per pad plus shipping by UPS

80 pads ~ $ 13.75 per pad plus shipping by UPS

Item# Rx722

5� x 7� Pads � Oversize Pads ~ Room to imprint up to 8 Doctor�s Names
1 part pads - 100 sheets per pad

1 part pads - 100 sheets per pad

20 pads ~ $14.90 per pad plus shipping by UPS

40 pads ~ $12.50 per pad plus shipping by UPS

60 pads ~ $11.75 per pad plus shipping by UPS

80 pads ~ $11.10 per pad plus shipping by UPS

2 part pads - 50 sets per pad (part 1 white security � part 2 BLANK yellow copy)
padded with wraparound cover

20 pads ~ $19.95 per pad plus shipping by UPS

40 pads ~ $16.10 per pad plus shipping by UPS

60 pads ~ $15.50 per pad plus shipping by UPS

80 pads ~ $ 13.75 per pad plus shipping by UPS

Item# Rx730

8-1/2�x3-2/3� Pads � Secure Pads ~ Room to imprint up to 4 Doctor�s Names
1 part pads - 100 sheets per pad

20 pads ~ $8.60 per pad plus shipping by UPS

40 pads ~ $6.85 per pad plus shipping by UPS

60 pads ~ $6.25 per pad plus shipping by UPS

80 pads ~ $5.85 per pad plus shipping by UPS

2 part pads - 50 sets per pad
(part 1 white security � part 2 PRINTED yellow copy)
padded with wraparound cover

20 pads ~ $14.70 per pad plus shipping by UPS

40 pads ~ $12.90 per pad plus shipping by UPS

80 pads ~ $ 8.50 per pad plus shipping by UPS

160 pads ~ $ 7.20 per pad plus shipping by UPS

IMPRINTING INFORMATION for upper portion of Prescription

Please fill-in the information that needs to be imprinted on the top of each sheet.
Un-imprinted forms are not available.

It is VERY IMPORTANT that you fill-in the information below carefully.
This is the information we will use to imprint your scripts.
You are responsible to make sure that all numbers that are to be printed on
your scripts (DEA# and License #) are entered correctly.
All information will be printed exactly as specified below

California Law requires that we print BOTH license Number AND DEA# on scripts

Suggested Format:

Practice Name
Doctor's Name Lic. Number DEA Number
Address
City, ST, Zip Code
Tel:, Fax:

Enter Prescription Paper Imprinting Information HERE

Printing additional names and/or locations on the back of the script is available at an additional charge.

Comments


CREDIT CARD INFORMATION
We accept Visa, MasterCard and American Express

Type Credit Card (Visa, MasterCard, Amex)

Credit Card Number

Exp. Date (MM/YY):

CCV Number ( found on the back of the card )

Bank Name on Card:

Card Holder's Name:

Credit Card Billing Address:
Zip Code:

After completing this FAX ORDER FORM .....
Please print this order form and send it by Fax to Micro Format Customer Service.
Our Fax Number is (847)520-0197
Thank You.

Under our licensing agreement, all order for Document Security Paper and Prescription Pads are reviewed and the information is confirmed by our Document Security Compliance Team. The use of Script Paper is controlled by Federal and State Agencies. Any attempt to purchase script paper by unauthorized persons or by persons providing falsified information will be reported to the proper authorities for prosecution to the full extent of the law.

Acceptance of any and all orders for document security and prescription paper will be determined by the Micro Format Document Security Compliance Team.

Orders ship within 12 to 15 business days from the time they are received by our order entry department.
Please allow extra time for shipping by UPS.

Thank you for your order.

Micro Format, Inc. ~ 830-3 Seton Court ~ Wheeling IL 60090
Area Code 847/520-4699 ~ Toll Free: 800-333-0549 ~ Fax: 847/520-0197
www.PrescriptionPaper.com ~ www.RxPaper.com ~ www.PrescriptionPads.net

copyright � 2004-2009 Micro Format, Inc. ~ Wheeling IL
All Rights Reserved