Practice Marketing & Office Supply Catalog 2019/2020 - 138

CLINICAL FORMS

PRESCRIPTION BLANKS

PREVENT FRAUD!

We Have the Level of Security Features You Require
A

, M.D.
SMITHress
JOHN
r Add
00000
123 You

B
Security Prescription
Blank
VOID VOID
VOID
JOHN SMITH,
M.D.
VOID VOID
VOID
VOID VOID VOID
VOID VOID VOID
VOID VOID VOID
VOID VOID VOID
8 SECURITY FEATURES
VOID VOID VOID
VOID VOID VOID
VOID VOID VOID
VOID VOID VOID
VOID VOID VOID
Premium, Horizontal
VOID VOID VOID
(1, 2, 3, 4, 5, 6, 7, 8)
VOID VOID VOID
VOID VOID VOID
123 YOUR ADDRESS
YOURTOWN, USA 00000
(000) 000-0000
Fax (000) 000-0000

VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID

NAME

S

D.O.B. __________________

ADDRESS ________________________________________________________

DATE ___________________

PRE-BOND

Security Features. Details on back.

PRESCRIPTION PADS
Premium, Vertical
Protective security features include:

JOHN SMITH, M.D.

____

________

123 Your Address
YOURTOWN, USA 00000
(000) 000-0000
Fax (000) 000-0000

__

________

____
____ AGE

________

________

________

____
________

Name ______________________________________________________________________________________
Address ______________________________________________________________ Date__________________

NO SECURITY

SECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITY

PATIENT _________________________________________________________

E
____ DAT

________

________

________

________

________

ADDRES

LIC# 00000
DEA # BA0000000

Touch Rx symbol, color will disappear then reappear.

WN, USA
YOURTO ) 000-0000
0
(000
) 000-000
Fax (000

Refill NR 1 2 3 4 5
Void After _________________________
_________________________
Signature
Prescription is void if more than one (1) controlled substance is written per blank.

Do Not Substitute-Dispense As Written

LABEL
REFILL

S

__TIME

________

________

.D.

______M

________

____
________

C

8 SECURITY FEATURES
(1, 2, 3, 4, 5, 6, 7, 8)

1. Chemically Reactive Paper-Changes color to indicate
exposure to chemical solvents, oxidants, acids, or alkalis
2. Heat-sensing Imprint-Disappears when touched

The word "VOID" appears in a continuous pattern when photocopied.

3. Invisible Fluorescent Fibers-Appear only under black light

JOHN

4. Void Pantograph-The word "VOID" appears when
blanks are scanned or photocopied

D

5. Microprint Safety Line-Appears as a solid rule, but
reads "Security Prescription" when magnified

JOHN SMITH, M.D.

NAME

123 Your Address
YOURTOWN, USA 00000
(000) 000-0000
Fax (000) 000-0000

________

ADDRES

SM

123 You ITH, M.D.
YOURTO r Address
WN,
(000) 000 USA 00000
Fax (000 -0000
) 000-000
0

________

________

S ____
________

________

________

____ DAT
E

________

________

____

____ AGE
____

JOHN SMITH, M.D.

Name ____________________________________________________________________________

________

__

123 Your Address
YOURTOWN, USA 00000
(000) 000-0000
Fax (000) 000-0000

Address ________________________________________ Date ____________________________

3 SECURITY FEATURES

6. Reverse Rx-Disappears if background color is lightened

________

________

(1, 3, 5)

Name __________________________________________________________________________

Refill NR 1 2 3 4 5

7. Security Features List-The back of the blank lists security features to
help deter fraudulent activity and to help officials determine authenticity

Prescription is void if more than one (1) prescription is written per blank.

LABEL

REFILL
________
Address ________________________________________
Date
__TIME
S

________

________

8. "Security Prescription" Background-The words "Security Prescription"
appear as a continuous pattern across the back of the blank

________

________

__M.D.

Woven background that exposes erasures and alterations.

# of Prescriptions
Total # of
# of
per Pad
Prescriptions
Item #
Format
No. of Parts
Size
Paper Color
Price
2@
4@
Pads
A. PREMIUM SECURITY PADS: The most secure available! Copy-proof, chemical-evident paper, with temperature-sensitive imprinting (Exceeds Medicaid Requirements).
368-0025 Horizontal
1-Part
5½" W x 4¼" H
G
10
100
101.99 79.99 64.99
Refill NR 1 2 31000
4 5
368-0054 Vertical
1-Part
4¼" W x 5½" H
G
10
100
1000
111.99 79.99 64.99
Prescription is void if more than one (1) prescription is written per blank.
368-0186 Horizontal
2-Part
5½" W x 4¼" H
G
10
50
500
174.99 141.99 131.99
368-0187 Vertical
2-Part
4¼" W x 5½" H
G
10
50
500
174.99 141.99 131.99
B. REGULAR Rx PADS: Available in 1-Part or 2-Part format with canary copy. Signature line can be added as per individual state law requirements.
368-0026 Horizontal
1-Part
5½" W x 4¼" H
W, B, C, G, P 10
100
1000
86.99 59.99 43.99
368-0051 Vertical
1-Part
4¼" W x 5½" H
W, B, C, G, P 10
100
1000
79.99 55.99 39.99
368-0027 Horizontal
2-Part
5½" W x 4¼" H
W
10
50
500
151.99 88.99 68.99
368-0052 Vertical
2-Part
4¼" W x 5½" H
W
10
50
500
142.99 83.99 64.99
C. HIGH-SECURITY Rx PADS: Special paper stock shows an unmistakable pattern if photocopied (Exceeds Medicaid Requirements).
368-0028 Horizontal
1-Part
5½" W x 4¼" H
W
10
100
1000
93.99 79.99 68.99
368-0053 Vertical
1-Part
4¼" W x 5½" H
W
10
100
1000
86.99 59.99 39.99
368-0188 Horizontal
2-Part
5½" W x 4¼" H
W
10
50
500
147.99 82.99 59.99
368-0189 Vertical
2-Part
4¼" W x 5½" H
W
10
50
500
145.99 81.99 58.99
D. SAFETY Rx PADS: Feature tamper-resistant blue-woven background to expose erasures or alterations.
368-0029 Horizontal
1-Part
5½" W x 4¼" H
Blue Safety
10
100
1000
100.99 71.99 54.99
368-0055 Vertical
1-Part
4¼" W x 5½" H
Blue Safety
10
100
1000
95.99 68.99 50.99
368-0190 Horizontal
2-Part
5½" W x 4¼" H
Blue Safety
10
50
500
156.99 120.99 86.99
368-0191 Vertical
2-Part
4¼" W x 5½" H
Blue Safety
10
50
500
156.99 120.99 86.99

Step

1 Select PAPER

Step

(only applies to Regular Rx Pads 1-Part)

White
(W)

138

Blue
(B)

Canary
(C)

www.henryscheindental.com

Green
(E)

2 Select DESIGN

Single Doctor/Single Address
YOURTOWN CLINIC

Pink
(P)

John Smith, M.D.
123 Your Address
Yourtown, USA 00000
(000) 000-0000
Fax (000) 000-0000

Lic. #
DEA #
NPI #

Multi Doctor/Multi Address

Doctor 1
Lic. # 1
DEA # 1
Doctor 2
Lic. # 2
DEA # 2
Doctor 3
Lic. # 3
DEA # 3
Doctor 4
Lic. # 4
DEA # 4
123 Your Address
Yourtown, USA 00000
(000) 000-0000
Fax (000) 000-0000
Practice Marketing & Office Supply Catalog 2019/2020

Table of Contents for the Digital Edition of Practice Marketing & Office Supply Catalog 2019/2020
