 www.CaliforniaPrescriptionPaper.com |
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California
TAMPER RESISTANT
Prescription Rx Pads
Custom Imprinted
Medical Prescription Scripts
for use in the State of California
~ This is a SECURE Order Form
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Micro Format is a California State Approved
manufacturer for Tamper Resistant Prescription Pads
ALL CALIFORNIA Rx FORMATS
MANUFACTURED BY MICRO FORMAT
ARE COMPLIANT WITH THE JANUARY 2019 REGULATION REQUIRING A SERIAL NUMBER
Micro Format Secure Prescription Pads contain all of
the features required by the California State Legislation.
After you complete your order ...
The California Law requires that a copy of your DEA Certificate 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 Certificate form on file.
Please FAX a copy of your DEA Certificate to
MICRO FORMAT Customer Service
Fax Number: (847)520-0197
Once we receive your DEA Certificate, it will be reviewed along with your order form. After it has been determined that everything is in order, your order will be processed.
PA prescription Authority DocumentationA 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.
MANUFACTURED BY MICRO FORMAT MEET 2019 REGULATIONS | ||||||
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Item# Rx710 1 part secure prescription  click to enlarge
Rx710 Click To Order |
| Item# Rx730 1 part secure prescription 
click to enlarge
Rx730 Click To Order |
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1 Part Script: Distinctive BLUE security background ~ 100 sheets per pad
All Prescription Pad Orders MUST BE ENTERED ON LINE We cannot accept orders for prescription pads by Fax. = |
California Prescription Pad Imprinting Information
and your Credit Card Payment Information will be requested
AFTER you have clicked on the "Add to Your SHOPPING CART" button
Due to State of California Regulations ~ Unimprinted forms are not available ~
When Requested,
Please accurately fill-in the information that needs to be imprinted on the top of each sheet.
- By California law, scripts must contain both DEA# and License # for each doctor listed.
- A copy of the DEA Registration for each doctor listed must be sent to us by FAX.
- Under California Law ... ALL California Laser Prescription Paper
MUST BE SHIPPED to the address on file with the DEA
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as required by the State of California | ||||
| Order Below
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ITEM# Rx710 Script Size: 5-1/2" x 4-1/4" Imprint up to 4 Names (3 Names plus Facility)
To Order ...
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Rx710 ONE PART SCRIPTS 100 sheets per pad |
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20 pads ~ $10.25 per pad plus shipping by UPS 40 pads ~ $8.25 per pad plus shipping UPS
60 pads ~ $7.75 per pad plus shipping by UPS
80 pads ~ $7.25 per pad plus shippingby UPS
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ITEM# Rx720 Oversize - Script Size: 5" x 7" Imprint up to 8 names
To Order ... |
Rx720 ONE PART SCRIPTS 100 sheets per pad |
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20 pads ~ $16.50 per pad plus shipping by UPS
40 pads ~ $13.75 per pad plus shipping by UPS
60 pads ~ $13.00 per pad plus shipping by UPS
80 pads ~ $12.25 per pad plus shipping by UPS
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ITEM# Rx722 Oversize - Script Size: 5" x 7" Recommend Imprinting up maximum 4 names
To Order ... |
Rx722 ONE PART SCRIPTS 100 sheets per pad |
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20 pads ~ $16.50 per pad plus shipping by UPS
40 pads ~ $13.75 per pad plus shipping by UPS
60 pads ~ $13.00 per pad plus shipping by UPS
80 pads ~ $12.25 per pad plus shipping by UPS
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ITEM# Rx730 Script Size: 8-1/2" x 3-2/3" Imprint up to 9 lines (4 Doctor's Names Maximum) Because of the size of the imprint area, each address will require 2 lines The address on one line; the Phone Number plus Fax Number on the second line.
An example is shown below:
To Order ... |
Rx730 ONE PART SCRIPTS 100 sheets per pad |
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20 pads ~ $9.50 per pad plus shipping by UPS
40 pads ~ $7.75 per pad plus shipping by UPS 60 pads ~ $7.00 per pad plus shipping by UPS
80 pads ~ $6.50 per pad plus shipping by UPS
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California Law 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
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.
Secure GuardTM Single Use Self Expiring Visitor Badges
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Additional Level of Security to your prescriptions with Tamper Evident Security Hologram Labels
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QUESTIONS: Please send us an e-mail support@rxpaper.com
Copyright © 2004- Micro Format, Inc., All Rights Reserved
Micro Format, Inc. Phone: 920-859-0500
Toll Free: 833-322-1882
Email: CustServ@RxMicroFormat.com
Address: 1434 Progress Lane, Omro, WI 54963
Rev 10/15