After completing all of the information,
print and send your order by FAX to (847)520-0197
You may also send your order by mail to:
Micro Format, Inc - RxPad Customer Service
830-3 Seton Court ~ Wheeling IL 60090

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

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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:

Is this order shipping to a residence ? (Yes or No)
(If yes, a signature will be required when package is delivered)

Daytime Phone (include Area Code):

Evening Phone (include Area Code):

e-mail: Fax Number:

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DEA #

State License # Expiration Date:

State Controlled Substance License No. (if applicable)

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SHIP TO ADDRESS (if different than above)

Practice Name:

Physician Name:

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

Address:

City: State: Zip:

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Choose Your Format.
Format Rx610 is designed for use when prescribing MORE THAN ONE MEDICATION.

Format Rx620 (shown above) includes the following text at the bottom of the script.
“PRESCRIPTION IS VOID IF MORE THAN ONE (1) PRESCRIPTION IS WRITTEN PER PAGE”

IMPORTANT ....
Indicate the Format Desired .....
Rx610
Rx620

Choose Number of Parts:
1 part
2 part (original and copy)

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Pad Size= 5-1/2” x 4-1/4”
Room to imprint 4 Doctor’s Names or 3 Names plus Facility Name

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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

Suggested Format:

Practice Name
Doctor's Name
Address
City, ST, Zip Code
Tel:, Fax:
(optional)Lic#, DEA#

Enter Prescription Paper Imprinting Information HERE

Comments

Please place "X" next to the number of pads needed.
1 part pads (100 sheets per pad)
20 pads ~ $6.70 per pad plus shipping by UPS
40 pads ~ $4.85 per pad plus shipping by UPS
80 pads ~ $3.50 per pad plus shipping by UPS
160 pads ~ $3.05 per pad plus shipping by UPS

2 part pads (50 sets per pad) original and copy
20 pads ~ $9.10 per pad plus shipping by UPS
40 pads ~ $7.87 per pad plus shipping by UPS
80 pads ~ $5.67 per pad plus shipping by UPS
160 pads ~ $4.49 per pad plus shipping by UPS

For an additional $3.85 per pad, prescription sheets and be consecutively numbered.

To add consecutive numbering,
place a "X" here
Enter STARTING NUMBER (i.e. 101):

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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:

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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.

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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.

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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