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  • California
    California Rx Pads

    Custom Imprinted
    Medical Prescription Scripts


    for use in the State of California

    ~ This is a SECURE Order Form ~

    Effective January 1, 2012, the Bureau of Criminal Identification and Investigative Services
    is responsible for oversight of the California Security Prescription Program.

    Micro Format is a California State Approved
    manufacturer for Tamper Resistant Prescription Pads


    Micro Format Secure Prescription Pads contain all of
    the features required by the California State Legislation.


    After you complete your order ...
    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 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.

    Pad Sizes Available
    Script Size: 5-1/2" x 4-1/4"
    Item# Rx710
    2 part secure prescription
    Click to Enlarge

    IMPORTANT:
    Part 2 is Blank

    click to enlarge


    Rx710
    Click To Order
    Two Oversize Secure Prescription Pads Available
    Script Size: 5" x 7"
    Item# Rx720
    2 part secure prescription

    IMPORTANT:
    Part 2 is Blank

    click to enlarge


    Rx720
    Click To Order
    Script Size: 5" x 7"
    Item# Rx722
    2 part secure prescription

    IMPORTANT:
    Part 2 is Blank


    click to enlarge


    Rx722
    Click To Order
    Script Size: 8-1/2" x 3-2/3"
    Item# Rx730
    2 part secure prescription


    Click to Enlarge


    IMPORTANT:
    This is the
    ONLY FORMAT
    for which we have
    received an exception.
    Part Two IS PRINTED

    Rx730
    Click To Order

    2 Part Scripts: Part 1 has distinctive BLUE security background
    Part 2 is a BLANK YELLOW sheet ~ 50 sets per pad - padded with wrap around cover


    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

    Printing on the BACK of each script is available at an additional charge of $5.00 per pad.
    This charge will not show on your order at the time you enter your order.
    This charge will be added to the invoice total when it is charged to your credit card.

    This charge will be added to the total price of your order.

    Included in this charge is printing THREE LINES of text copy
    Information must fit into THREE LINES of TEXT copy.

      Three lines of text copy may be:

    • THREE NAMES plus license numbers
    • TWO NAMES plus ONE LOCATION
    • THREE LOCATIONS
    • Other combination of names and locations

    If additional information needs to be printed on the back of each script,
    an additional COMPOSITION charge of $100.00 will be added to the total price for this order.
    You will be required to sign a composition approval before your order will be printed.

    For additional information please CALL Customer Service at (800)333-0549.

    Order Below

    ITEM# Rx710
    Script Size: 5-1/2" x 4-1/4"
    Imprint up to 4 Names
    (3 Names plus Facility)

    Click to Enlarge

    To Order ...
    click on the
    "Add to Your SHOPPING CART"
    button.


    IMPORTANT:
    Part Two IS BLANK

    Rx710
    TWO PART SCRIPTS
    50 sets per pad
    with wrap around cover
    Note: Part 2 is a
    BLANK YELLOW sheet

    20 pads ~ $13.25 per pad
    plus shipping
    by UPS


    40 pads ~ $11.50 per pad
    plus shipping
    by UPS


    60 pads ~ $10.50 per pad
    plus shipping
    by UPS


    80 pads ~ $9.00 per pad
    plus shipping
    by UPS


    ITEM# Rx720
    Oversize - Script Size: 5" x 7"
    Imprint up to 8 names

    To Order ...
    click on the
    "Add to Your SHOPPING CART"
    button.


    IMPORTANT:
    Part Two IS BLANK

    Rx720
    TWO PART SCRIPTS
    50 sets per pad
    with wrap around cover
    Note: Part 2 is a
    BLANK YELLOW sheet

    20 pads ~ $22.00 per pad
    plus shipping
    by UPS


    40 pads ~ $17.75 per pad
    plus shipping
    by UPS


    60 pads ~ $17.00 per pad
    plus shipping
    by UPS


    80 pads ~ $15.25 per pad
    plus shipping
    by UPS


    ITEM# Rx722
    Oversize - Script Size: 5" x 7"
    Recommend Imprinting up maximum 4 names

    To Order ...
    click on the
    "Add to Your SHOPPING CART"
    button.


    IMPORTANT:
    Part Two IS BLANK

    Rx722
    TWO PART SCRIPTS
    50 sets per pad
    with wrap around cover
    Note: Part 2 is a
    BLANK YELLOW sheet

    20 pads ~ $22.00 per pad
    plus shipping
    by UPS


    40 pads ~ $17.75 per pad
    plus shipping
    by UPS


    60 pads ~ $17.00 per pad
    plus shipping
    by UPS


    80 pads ~ $15.25 per pad
    plus shipping
    by UPS


    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:
    Practice Name, 2 Doctor's Names,
    3 Addresses, Phone Numbers
    and Fax = 9 lines.


    Click to Enlarge

    To Order ...
    click on the
    "Add to Your SHOPPING CART"
    button.


    IMPORTANT:
    This is the ONLY FORMAT for which we have received an exception.

    Part Two IS PRINTED


    Rx730
    TWO PART SCRIPTS
    50 sets per pad
    with wrap around cover
    Note: Part 2 is a
    PRINTED YELLOW sheet
    with no security features.

    20 pads ~ $16.25 per pad
    plus shipping
    by UPS


    40 pads ~ $14.25 per pad
    plus shipping
    by UPS


    80 pads ~ $9.50 per pad
    plus shipping
    by UPS


    160 pads ~ $8.00 per pad
    plus shipping
    by UPS



    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
    Self Expiring Visitor Badges
    Add an
    Additional Level of Security
    to your prescriptions
    with Tamper Evident
    Security Hologram Labels

    Gold Security Hologram Labels



    QUESTIONS: Please send us an e-mail support@rxpaper.com
    Copyright © 2004- Micro Format, Inc., All Rights Reserved

    Micro Format, Inc. 
    830-3 Seton Court ~ Wheeling, IL 60090 
    847/520-4699 FAX 847/520-0197
    800-333-0549


    Rev 10/15