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P40 Prescription Pad Proof
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Name of Office:
"; echo "
Physcian/PA Name #1 w/NPI#:
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Physcian/PA Name #2 w/NPI#:
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Address:
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City:
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State:
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Email 2:
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Email 2:
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Email 2:
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Starting Number:
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Name of Office:
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Physcian/
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PA Name w/NPI#:
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Physcian/
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PA Name w/NPI#:
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Address:
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City:
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State:
"; echo "
Zip:
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Phone:
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Fax:
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MMMI:
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Starting Number:
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Paper Options:
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1 Part (100 scripts per pad)
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2 Part (50 scripts per pad)
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Finish Options:
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None
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2 Hole Drilling at Top
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For some older versions of Internet Explorer, preview mode will not
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function correctly. Press Continue to see a proof of prescription pad.
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