Practice Marketing & Office Supply Catalog 2021/2022 - 149

STATE-APPROVED PRESCRIPTION BLANKS

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

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

Horizontal	1-Part	
Horizontal	2-Part	

3

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.

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

Lic. #
DEA #
NPI #

Total # of 	
Prescriptions	

	
	
	
	

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

Price	

2@	

4@

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

1000	
500	

137.99	
158.99	

93.99	
104.99	

72.99
79.99

1000	
500	
1000	
500	

106.99	
149.99	
97.99	
141.99	

75.99	
95.99	
67.99	
89.99	

48.99
71.99
45.99
68.99

1000	
500	

95.99	
140.99	

63.99	
89.99	

55.99
67.99

1000	
500	

98.99	
112.99	

78.99	
78.99	

67.99
58.99

1000	
500	

94.99	
141.99	

63.99	
91.99	

54.99
67.99

100	
50	

1000	
500	

117.99	
159.99	

79.99	
102.99	

59.99
73.99

100	
50	
100	

1000	
500	
1000	

133.99	
187.99	
185.99	

99.99	
111.99	
135.99	

74.99
88.99
105.99

5½ " W x 4¼ " H	10	
5½ " W x 4¼ " H	10	

100	
50	

1000	
500	

113.99	
171.99	

75.99	
110.99	

58.99
79.99

5½ " W x 4¼ " H	10	
5½ " W x 4¼ " H	10	

100	
50	

1000	
500	

94.99	
141.99	

63.99	
92.99	

54.99
67.99

5½ " W x 4¼ " H	
5½ " W x 4¼ " H	

100	
50	

1000	
500	

94.99	
149.99	

64.99	
138.99	

48.99
107.99

5½ " W x 4¼ " H	
5½ " W x 4¼ " H	

10 	
10 	

NEW JERSEY

3. 368-1705	 Vertical	1-Part	

4¼ " W x 5½ " H	10	
368-1706	 Vertical	2-Part	
4¼ " W x 5½ " H	10	
368-1999	
Vertical	
1-Part w/Backprint	 4¼ " W x 5½ " H	10	

WASHINGTON
368-0042	 Horizontal	1-Part	
368-0043	 Horizontal	2-Part	
WEST VIRGINIA
368-0044	 Horizontal	1-Part	
368-0045	 Horizontal	2-Part	
WYOMING
368-0047	 Horizontal	1-Part	
368-0048	 Horizontal	2-Part	
			

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Name ____________________________________________________________________________

							
# of	
# of Prescriptions	
Item #	
Format	
No. of Parts	
Size	
Pads	
per Pad	
CALIFORNIA
1. 368-0032	 Horizontal	1-Part	
5½ " W x 4¼ " H	10	
50	
368-0033	 Horizontal	2-Part	
5½ " W x 4¼ " H	10	
50	
368-0056	 Vertical	1-Part	
4¼ " W x 5½ " H	10	
50	
4¼ " W x 5½ " H	10	
50	
368-0057	 Vertical	2-Part	
DELAWARE
368-0058	 Horizontal	1-Part	
5½ " W x 4¼ " H	10	
100	
368-0059	 Horizontal	2-Part	
5½ " W x 4¼ " H	
10 	
50	
FLORIDA
368-0034	 Horizontal	1-Part	
5½ " W x 4¼ " H	10	
100	
368-0035	 Horizontal	2-Part	
5½ " W x 4¼ " H	10	
50	
4¼ " W x 5½ " H	
10 	
100	
368-0049	 Vertical	1-Part	
368-0050	 Vertical	2-Part	
4¼ " W x 5½ " H	10	
50	
GEORGIA
367-7953	 Horizontal	1-Part	
5½ " W x 4¼ " H	10	
100	
367-7955	 Horizontal	2-Part	
5½ " W x 4¼ " H	
10 	
50	
INDIANA
2. 368-0030	 Horizontal	1-Part	
5½ " W x 4¼ " H	
10 	
100	
368-0031	 Horizontal	2-Part	
5½ " W x 4¼ " H	
10 	
50	
KENTUCKY
368-0040	 Horizontal	1-Part	
5½ " W x 4¼ " H	
10 	
100	
368-0041	 Horizontal	2-Part	
5½ " W x 4¼ " H	
10 	
50	
MAINE
368-0038	
368-0039	

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JOHN SMITH, M.D.

New Jersey, Vertical

California, Vertical

California, Horizontal

Indiana, Horizontal

2

1

10 	
10 	

CLINICAL FORMS

We Have Your State-Approved Prescription Forms

For Imprinted Materials, contact: professional.promotions@henryschein.com

For Imprinted Materials, contact: professional.promotions@henryschein.com

To order, visit: www.henryscheindental.com

149
Practice Marketing & Office Supply Catalog 2021/2022

Table of Contents for the Digital Edition of Practice Marketing & Office Supply Catalog 2021/2022
