CLINICAL FORMS LASER PRESCRIPTION FORMS A B C D E F G H STATE-APPROVED LASER PRESCRIPTION BLANK FORMS * Forms comply with the most current individual state regulations * All papers meet " tamper-resistant " Medicaid requirements effective October 2008 * Paper size: 81 ⁄2 " W x 11 " H * For other approved state forms visit henryscheindentalcom A Florida Full Sheet (367-7818)1000 per Pkg 2 Pkg@ B Florida Full Sheet with Detachable Top-Left Script (367-7821)1000 per Pkg 2 Pkg@ C Georgia Full Sheet (367-7862)500 sheets/pkg 2 Pkg@ D Indiana Full Sheet with Detachable Top-Left Script (367-5294)500 per Pkg 2 Pkg@ E Kentucky Full Sheet with Detachable Top-Left Script (367-5861)500 per Pkg 2 Pkg@ F Washington State Full Sheet (367-7298)500 per Pkg 2 Pkg@ G Washington State Full Sheet with Detachable Top-Left Script (367-7300)500 per Pkg 2 Pkg@ H Washington State 1 ⁄4 Perforated Sheet (367-7299)500 per Pkg 2 Pkg@ * All products featured here are NOT for use in other states For Imprinted Materials, contact: professional.promotions@henryschein.com For pricing information and/or to place an order, visit: www.henryscheindental.com 153 Compatible with Compatible with Compatible with Compatible with Compatible with Compatible with Compatible withhttp://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx?productid=3677818&CatalogName=DENTAL&utm_source=Dental&utm_medium=Nxtbook&utm_campaign=practicemarketing20222023&utm_term=3677818 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx?productid=3675861&CatalogName=DENTAL&utm_source=Dental&utm_medium=Nxtbook&utm_campaign=practicemarketing20222023&utm_term=3675861 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx?productid=3677821&CatalogName=DENTAL&utm_source=Dental&utm_medium=Nxtbook&utm_campaign=practicemarketing20222023&utm_term=3677821 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx?productid=3677298&CatalogName=DENTAL&utm_source=Dental&utm_medium=Nxtbook&utm_campaign=practicemarketing20222023&utm_term=3677298 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx?productid=3677862&CatalogName=DENTAL&utm_source=Dental&utm_medium=Nxtbook&utm_campaign=practicemarketing20222023&utm_term=3677862 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx?productid=3677300&CatalogName=DENTAL&utm_source=Dental&utm_medium=Nxtbook&utm_campaign=practicemarketing20222023&utm_term=3677300 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx?productid=3675294&CatalogName=DENTAL&utm_source=Dental&utm_medium=Nxtbook&utm_campaign=practicemarketing20222023&utm_term=3675294 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx?productid=3677299&CatalogName=DENTAL&utm_source=Dental&utm_medium=Nxtbook&utm_campaign=practicemarketing20222023&utm_term=3677299 http://www.henryscheindental.com