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Custom Imprinted
Medical Prescription Scripts
for use in the State of New Jersey

For NEW JERSEY prescription forms
Micro Format is a distributor for PRINTCO, INC.
PRINTCO is a New Jersey approved manufacturer for Prescription Pads and Laser Scripts.
The state of New Jersey has made changes to their prescription form program.
The changes will improve the security of all New Jersey Rx forms by adding security features to reduce fraud.
Click for additional details.
PLACE YOUR ORDER TODAY.
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Order Form
~This is a SECURE Order Form ~
PRINTCO Imprinted Prescription Pads
meet all of the requirements legislated by the State of New Jersey.
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All Prescription Pad Orders MUST BE ENTERED ON LINE
We cannot accept orders for prescription pads by Fax.
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VERY IMPORTANT
New Jersey State Law requires that all Rx Paper Orders are shipped to the address on file with the State of New Jersey.
After submitting your order .....
the Micro Format Compliance Department on behalf of Printco, Inc., requires that you
send a copy of your State License to our customer service department by FAX
FAX Number (847)520-0197
Orders will be processed ONLY after we have received a copy of your State License by Fax.
Failure to send your License will delay the production of your order.
NOTICE
WITHOUT EXCEPTION,
Your order WILL NOT BE PROCESSED until your License has been received.
It is for your protection.
We appreciate your co-operation with this requirement.
New Jersey State Law requires that Micro Format on behalf of Printco, Inc., maintain on file the signature for each prescriber that appears on the script.
If more than one prescriber appears, the RESPONSIBLE PRESCRIBER must be indicated.
Please visit
www.newjerseyrxpaper.com/FileSignature.pdf
to obtain the required signature document.
Please complete this document and send it by FAX to Micro Format, Inc.
FAX# 847-520-0197
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Order 1 part pads Below
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MD, DO, DS, DMD, DPM, DVM
Script Size: 4" x 5-1/2"
Imprint up to 4 Names or 2 Names plus Facility Name
Each name must be imprinted with License # and NPI #

To Order ...
click on the
"Add to Your SHOPPING CART"
button.
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MD, DO, DS, DMD, DPM, DVM ONE PART SCRIPTS 100 sheets per pad
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20 pads ~ 1 part ~ $9.75 per pad plus shippingby UPS
40 pads ~ 1 part ~ $7.25 per pad plus shipping by UPS
80 pads ~ 1 part ~ $6.25 per pad plus shipping by UPS
120 pads ~ 1 part ~ $6.00 per pad plus shipping by UPS
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Physician Assistant
Script Size: 4" x 5-1/2"

click to enlarge
If you are ordering the Physician Assistant format
New Jersey law requires only ONE Physician Assistant's name per script
with ONE Collaborative Physician's name.
Both the Physician Assistant's name and information plus
the Collaborative Physician's name and information must be pre-printed on script.
To Order ...
click on the
"Add to Your SHOPPING CART"
button.
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Physician Assistant
ONE PART SCRIPTS 100 sheets per pad |
20 pads ~ 1 part ~ $11.00 per pad plus shippingby UPS
40 pads ~ 1 part ~ $8.50 per pad plus shipping by UPS
80 pads ~ 1 part ~ $8.00 per pad plus shipping by UPS
120 pads ~ 1 part ~ $7.50 per pad plus shipping by UPS
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Nurse Practitioner
Script Size: 4" x 5-1/2"

click to enlarge
If you are ordering the Nurse Practitioner format
New Jersey law requires only ONE Nurse Practitioner's name per script
with ONE Collaborative Physician's name.
Both the Nurse Practitioner's name and information plus
the Collaborative Physician's name and information must be pre-printed on script.
To Order ...
click on the
"Add to Your SHOPPING CART"
button.
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Nurse Practitioner
ONE PART SCRIPTS 100 sheets per pad |
20 pads ~ 1 part ~ $11.00 per pad plus shipping by UPS
40 pads ~ 1 part ~ $8.50 per pad plus shipping by UPS
80 pads ~ 1 part ~ $8.00 per pad plus shipping by UPS
120 pads ~ 1 part ~ $7.50 per pad plus shipping by UPS
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Facility Format
Script Size: 4" x 5-1/2"

click to enlarge
Imprint the Facility Name and Facility Number, Address and Phone Number.
Only ONE LOCATION may appear on the front of the script.
Additional locations may be printed on back of the script
(at an additional charge).
To Order ...
click on the
"Add to Your SHOPPING CART"
button.
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Facility Format Facility ONE PART SCRIPTS 100 sheets per pad |
20 pads ~ 1 part ~ $11.00 per pad plus shippingby UPS
40 pads ~ 1 part ~ $8.50 per pad plus shipping by UPS
80 pads ~ 1 part ~ $8.00 per pad plus shippingby UPS
120 pads ~ 1 part ~ $7.50 per pad plus shipping by UPS
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Midwife
Script Size: 4" x 5-1/2"

click to enlarge
To Order ...
click on the
"Add to Your SHOPPING CART"
button.
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Midwife
ONE PART SCRIPTS 100 sheets per pad |
20 pads ~ 1 part ~ $11.00 per pad plus shippingby UPS
40 pads ~ 1 part ~ $8.50 per pad plus shipping by UPS
80 pads ~ 1 part ~ $8.00 per pad plus shipping by UPS
120 pads ~ 1 part ~ $7.50 per pad plus shipping by UPS
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Optometrist Format
Script Size: 4" x 5-1/2"
Imprint maximum 4 Names or 3 Names plus Facility Name.
Each name must be imprinted with License # and NPI #

click to enlarge
To Order ...
click on the
"Add to Your SHOPPING CART"
button.
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Optometrist Format ONE PART SCRIPTS 100 sheets per pad |
20 pads ~ 1 part ~ $11.00 per pad plus shipping by UPS
40 pads ~ 1 part ~ $8.50 per pad plus shipping by UPS
80 pads ~ 1 part ~ $8.00 per pad plus shipping by UPS
120 pads ~ 1 part ~ $7.50 per pad plus shipping by UPS
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EYEWEAR Format
Script Size: 4" x 5-1/2"
Imprint maximum 4 Names or 3 Names plus Facility Name.
Each name must be imprinted with License # and NPI #

click to enlarge
To Order ...
click on the
"Add to Your SHOPPING CART"
button.
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EYEWEAR Format ONE PART SCRIPTS 100 sheets per pad |
20 pads ~ 1 part ~ $11.00 per pad plus shipping by UPS
40 pads ~ 1 part ~ $8.50 per pad plus shipping by UPS
80 pads ~ 1 part ~ $8.00 per pad plus shipping by UPS
120 pads ~ 1 part ~ $7.50 per pad plus shipping by UPS
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Thank You for your order for Secure New Jersey Prescription Forms.
We appreciate your business.
Your order will ship in approximately 10 to 12 business days.
Please allow up to 4 days for shipping by UPS.
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
Phone: 847/520-4699 ~ 800-333-0549
Fax 847/520-0197
rev 04/2014
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