For NEW JERSEY prescription forms
Micro Format is a distributor for PRINTCO, INC.
PRINTCO is a New Jersey approved manufacturer for NJ Prescription Pads

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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Available Formats
MD, DO, DS, DMD, DPM, DVM click to enlarge	Physician Assistant click to enlarge	Nurse Practitioner click to enlarge	Facility Format click to enlarge	Midwife click to enlarge	Optometrist Format click to enlarge	EYEWEAR click to enlarge
MD, DO, DS Click To Order 2 part pads	PA Click To Order 2 part pads	NP Click To Order 2 part pads	FACILITY Click To Order 2 part pads	MIDWIFE Click To Order 2 part pads	OPTOMETRIST Click To Order 2 part pads	EYEWEAR Click To Order 2 part pads

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Order 2 part pads Below
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.	MD, DO, DS, DMD, DPM, DVM TWO PART SCRIPTS 50 sets per pad with wrap around cover Note: Part 2 is a BLANK YELLOW sheet
	20 pads (50 sets per pad) ~ 2 part ~ $10.75 per pad plus shippingby UPS 40 pads (50 sets per pad) ~ 2 part ~ $8.25 per pad plus shipping by UPS 80 pads (50 sets per pad ~ 2 part ~ $6.50 per pad plus shipping by UPS 120 pads (50 sets per pad) ~ 2 part ~ $6.25 per pad plus shipping by UPS
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.	Physician Assistant TWO PART SCRIPTS 50 sets per pad with wrap around cover Note: Part 2 is a BLANK YELLOW sheet
	20 pads (50 sets per pad) ~ 2 part ~ $12.50 per pad plus shippingby UPS 40 pads (50 sets per pad) ~ 2 part ~ $10.50 per pad plus shipping by UPS 80 pads (50 sets per pad) ~ 2 part ~ $9.00 per pad plus shipping by UPS 120 pads (50 sets per pad) ~ 2 part ~ $8.75 per pad plus shipping by UPS
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.	Nurse Practitioner TWO PART SCRIPTS 50 sets per pad with wrap around cover Note: Part 2 is a BLANK YELLOW sheet
	20 pads (50 sets per pad) ~ 2 part ~ $12.50 per pad plus shipping by UPS 40 pads (50 sets per pad) ~ 2 part ~ $10.50 per pad plus shipping by UPS 80 pads (50 sets per pad) ~ 2 part ~ $9.00 per pad plus shipping by UPS 120 pads (50 sets per pad) ~ 2 part ~ $8.75 per pad plus shipping by UPS
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.	Facility Format TWO PART SCRIPTS 50 sets per pad with wrap around cover Note: Part 2 is a BLANK YELLOW sheet
	20 pads (50 sets per pad) ~ 2 part ~ $12.50 per pad plus shippingby UPS 40 pads (50 sets per pad) ~ 2 part ~ $10.50 per pad plus shipping by UPS 80 pads (50 sets per pad) ~ 2 part ~ $9.00 per pad plus shippingby UPS 120 pads (50 sets per pad) ~ 2 part ~ $8.75 per pad plus shipping by UPS
Midwife Script Size: 4" x 5-1/2" click to enlarge To Order ... click on the "Add to Your SHOPPING CART" button.	Midwife TWO PART SCRIPTS 50 sets per pad with wrap around cover Note: Part 2 is a BLANK YELLOW sheet
	20 pads (50 sets per pad) ~ 2 part ~ $12.50 per pad plus shippingby UPS 40 pads (50 sets per pad) ~ 2 part ~ $10.50 per pad plus shipping by UPS 80 pads (50 sets per pad) ~ 2 part ~ $9.00 per pad plus shipping by UPS 120 pads (50 sets per pad) ~ 2 part ~ $8.75 per pad plus shipping by UPS
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.	Optometrist Format TWO PART SCRIPTS 50 sets per pad with wrap around cover Note: Part 2 is a BLANK YELLOW sheet
	20 pads (50 sets per pad) ~ 2 part ~ $12.50 per pad plus shipping by UPS 40 pads (50 sets per pad) ~ 2 part ~ $10.50 per pad plus shipping by UPS 80 pads (50 sets per pad) ~ 2 part ~ $9.00 per pad plus shipping by UPS 120 pads (50 sets per pad) ~ 2 part ~ $8.75 per pad plus shipping by UPS
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.	EYEWEAR Format TWO PART SCRIPTS 50 sets per pad with wrap around cover Note: Part 2 is a BLANK YELLOW sheet
	20 pads (50 sets per pad) ~ 2 part ~ $12.50 per pad plus shipping by UPS 40 pads (50 sets per pad) ~ 2 part ~ $10.50 per pad plus shipping by UPS 80 pads (50 sets per pad) ~ 2 part ~ $9.00 per pad plus shipping by UPS 120 pads (50 sets per pad) ~ 2 part ~ $8.75 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.