rx-form

Type clearly how you want the information to appear on your scripts. After entering in all of the information you want pre-printed on your Rx pads, generate and review your proof to ensure all of the information looks correct before proceeding to payment.

DEA Number *

NPI Number *

License Number * License Number is required for verification. If you do not want your License Number printed on the scripts, select 'No' below.

Print License Number *

Yes No

By selecting 'Yes,' the information typed in the License Number field will be printed on the scripts. Select 'No' if you do not want that content printed.

Name and Degree * The degree included after your name in the above field will be added to the signature line. In some instances, multiple degrees will be shortened on the signature line.

Clinic / Hospital *

Specialty *

Street Address *

City *

State *

Zip Code *

Telephone Number *

Fax Number

Copy of DEA or Medical License * For first time orders, upload a copy of your DEA certificate or medical license here. Orders will not be processed without this information on file. Alternatively, you may email or fax us this information after you have submitted your order.

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