Practice Marketing & Office Supply Catalog 2020/2021 - 139
STATE-APPROVED PRESCRIPTION BLANKS
* Manufactured with highly specialized, state-mandated security paper and inks
* Pricing includes imprinting of all necessary practice and licensing information
* Additional charges will apply for the sequential numbering for states where
there is no requirement
* Additional charges will apply for back printing of forms
* Not all state forms are shown above
Item #
Format
No. of Parts
Size
CALIFORNIA
1. 368-0032
Horizontal
1-Part
5½"W x 4¼"H
368-0033
Horizontal
2-Part
5½"W x 4¼"H
368-0056
Vertical
1-Part
4¼"W x 5½"H
368-0057
Vertical
2-Part
4¼"W x 5½"H
DELAWARE
368-0058
Horizontal
1-Part
5½"W x 4¼"H
368-0059
Horizontal
2-Part
5½"W x 4¼"H
FLORIDA
368-0034
Horizontal
1-Part
5½"W x 4¼"H
368-0035
Horizontal
2-Part
5½"W x 4¼"H
368-0049
Vertical
1-Part
4¼"W x 5½"H
368-0050
Vertical
2-Part
4¼"W x 5½"H
GEORGIA
367-7953
Horizontal
1-Part
5½"W x 4¼"H
367-7955
Horizontal
2-Part
5½"W x 4¼"H
INDIANA
2. 368-0030
Horizontal
1-Part
5½"W x 4¼"H
368-0031
Horizontal
2-Part
5½"W x 4¼"H
KENTUCKY
368-0040
Horizontal
1-Part
5½"W x 4¼"H
368-0041
Horizontal
2-Part
5½"W x 4¼"H
MAINE
368-0038
368-0039
NEW JERSEY
3. 368-1705
368-1706
368-1999
# of
Pads
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
VOID
JOHN SMITH, M.D.
123 Your Address
YOURTOWN, USA 00000
(000) 000-0000
Fax (000) 000-0000
VO I
VO I
VO I
VO I
VO I
VO I
VO I
VOI
3
Name ____________________________________________________________________________
Address ________________________________________ Date ____________________________
Refill NR 1 2 3 4 5 Void after __________________________
Dispense as Written
May Substitute
1-24
25-49
50-74
75-100
101-150
151 and over
Prescription is void if more than one (1) prescription is written per blank.
New Jersey, Vertical
California, Vertical
California, Horizontal
STATE-APPROVED PRESCRIPTION BLANKS
Indiana, Horizontal
2
1
IMPRINT OPTIONS:
Single Doctor/Single Address
YOURTOWN CLINIC
John Smith, M.D.
123 Your Address
Yourtown, USA 00000
(000) 000-0000
Fax (000) 000-0000
# of Prescriptions
per Pad
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
Total # of
Prescriptions
Price
2@
4@
10
10
10
10
50
50
50
50
500
500
500
500
110.99
183.99
99.99
171.99
65.99
116.99
61.99
109.99
45.99
84.99
42.99
79.99
10
10
100
50
1000
500
137.99
158.99
93.99
104.99
72.99
79.99
10
10
10
10
100
50
100
50
1000
500
1000
500
106.99
149.99
97.99
141.99
72.99
95.99
67.99
89.99
48.99
71.99
45.99
68.99
10
10
100
50
1000
500
95.99
140.99
63.99
89.99
55.99
67.99
10
10
100
50
1000
500
98.99
112.99
78.99
78.99
67.99
58.99
10
10
100
50
1000
500
94.99
141.99
63.99
91.99
54.99
67.99
Horizontal
Horizontal
1-Part
2-Part
5½"W x 4¼"H
5½"W x 4¼"H
10
10
100
50
1000
500
117.99
159.99
79.99
102.99
59.99
73.99
Vertical
Vertical
Vertical
1-Part
4¼"W x 5½"H
2-Part
4¼"W x 5½"H
1-Part w/Backprint 4¼"W x 5½"H
10
10
10
100
50
100
1000
500
1000
133.99
187.99
185.99
99.99
111.99
135.99
99.99
88.99
105.99
1-Part
2-Part
5½"W x 4¼"H
5½"W x 4¼"H
10
10
100
50
1000
500
113.99
171.99
75.99
110.99
58.99
79.99
1-Part
2-Part
5½"W x 4¼"H
5½"W x 4¼"H
10
10
100
50
1000
500
94.99
141.99
63.99
92.99
54.99
67.99
1-Part
2-Part
5½"W x 4¼"H
5½"W x 4¼"H
10
10
100
50
1000
500
94.99
149.99
64.99
138.99
48.99
107.99
WASHINGTON
368-0042
Horizontal
368-0043
Horizontal
WEST VIRGINIA
368-0044
Horizontal
368-0045
Horizontal
WYOMING
368-0047
Horizontal
368-0048
Horizontal
For Imprinted Materials, contact: professional.promotions@henryschein.com
For Imprinted Materials, contact: professional.promotions@henryschein.com
20DC2250_Clinical_Forms_p134-148 copy_cjb.indd 139
CLINICAL FORMS
We Have Your State-Approved Prescription Forms
To order, visit: www.henryscheindental.com
139
3/24/20 9:30 AM
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Practice Marketing & Office Supply Catalog 2020/2021
Table of Contents for the Digital Edition of Practice Marketing & Office Supply Catalog 2020/2021
Table of Contents
Practice Marketing & Office Supply Catalog 2020/2021 - Cover1
Practice Marketing & Office Supply Catalog 2020/2021 - Cover2
Practice Marketing & Office Supply Catalog 2020/2021 - Table of Contents
Practice Marketing & Office Supply Catalog 2020/2021 - 2
Practice Marketing & Office Supply Catalog 2020/2021 - 3
Practice Marketing & Office Supply Catalog 2020/2021 - 4
Practice Marketing & Office Supply Catalog 2020/2021 - 5
Practice Marketing & Office Supply Catalog 2020/2021 - 6
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