Practice Marketing & Office Supply Catalog 2020/2021 - 140

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

D.O.B. __________________

DATE ___________________

Touch Rx symbol, color will disappear then reappear.

PRE-BOND

Security Features. Details on back.

PRESCRIPTION PADS
Premium, Vertical
Protective security features include:

____
S ____

DATE

JOHN SMITH, M.D.

____

________

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

__

________

____
____ AGE

________

________

____
________

Name ______________________________________________________________________________________
Address ______________________________________________________________ Date__________________

NO SECURITY

SECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITYRXSECURITY

ADDRESS ________________________________________________________

________

________

________

________

ADDRES

LIC# 00000
DEA # BA0000000

PATIENT _________________________________________________________

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

________

__M.D.

________

________

________

________

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 ____
____

________

________

________

________

________

________

____

AGE ____

JOHN SMITH, M.D.
________

__

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

____ DAT
E

________

Name ____________________________________________________________________________

(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.

Total # of
								
# of 	 # of Prescriptions
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)

140

Blue
(B)

Canary
(C)

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

To order, visit: www.henryscheindental.com

20DC2250_Clinical_Forms_p134-148 copy_cjb.indd 140

3/13/20 3:35 PM
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