State-Approved Laser Prescription Blanks CLINICAL FORMS B A C le with Compatib le with Compatib F D le with Compatib G K le with Compatib I le with Compatib L le with Compatib CLINICAL FORMS J le with Compatib H le with Compatib E le with Compatib N M le with Compatib STATE-APPROVED LASER PRESCRIPTION BLANKS * Forms comply with the most current individual state regulations * All papers meet "tamper-resistant" Medicaid requirements effective October 2008 * Paper size: 8-1⁄2"W x 11"H Item# Description A. (367-5867) Alaska Full Sheet with Detachable Top Left Script B. (368-0184) Delaware Full Sheet C. (367-7818) Florida Full Sheet D. (367-7821) Florida Full Sheet with Detachable Top Left Script E. (367-7819) Florida 1/2 Perforated Sheet F. (367-7820) Florida 1/4 Perforated Sheet G. (367-7862) Georgia Full Sheet H. (367-5294) Indiana Full Sheet with Detachable Top Left Script Qty. Price 2@ 500/PK 1000/PK 1000/PK 1000/PK $69.99 $199.99 $219.99 $219.99 $65.99 $189.99 $209.99 $209.99 1000/PK 1000/PK 1000/PK 500/PK $219.99 $219.99 $99.99 $94.99 $209.99 $209.99 $94.99 $89.99 Item# Description I. (367-5861) Kentucky Full Sheet with Detachable Top Left Script J. (367-5296) Maine Full Sheet with Detachable Top Left Script K. (367-7298) Washington State Full Sheet L. (367-7300) Washington State Full Sheet with Detachable Top Left Script M. (367-7295) Washington State 1/2 Perforated Sheet N. (367-7299) Washington State 1/4 Perforated Sheet Qty. 500/PK Price $129.99 2@ $119.99 500/PK $159.99 $149.99 500/PK 500/PK $84.99 $69.99 $80.99 $65.99 500/PK 500/PK $84.99 $69.99 $80.99 $65.99 All products featured on this page are NOT for use in other states. Imprinted Materials: 800.414.0940 8am-5pm (ET) Call To Order: 800.372.4346 8am-9pm (ET) 179http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675861%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675867%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3680184%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675296%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677818%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677821%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677298%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677300%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677819%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677820%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677295%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677862%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3677299%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675294%26CatalogName%3DDENTAL