Hand Written Prescription Sheet Order Form

There are two steps to Ordering:
1. Tell us what you want printed on the Prescription Sheets.

2. "BUY NOW" This is where you give us your license numbers, and tell us where to ship
your order, etc. (Remember: FREE SHIPPING!)

TELL US WHO YOU ARE

Practice Name
(If applicable)

Mr/Ms/Mrs

First Name

Last Name

Title/Position

Street Address

City

State

Zip

Telephone

FAX Number
(We need to send you a proof)

Email Address

YES

PRESCRIPTION SHEET DESIGN

1000 (Minimum Order)

Quantity

3000 sheets

2000 Sheets

V-1

V-2

H-1

Style

H-2

Click here to see sample of each design

COPY TO BE PRINTED ON SHEETS

Doctor's Name at bottom of Scrip

Street Address

City

State

Zip

Telephone

I want my License Number Printed on the Sheet

YES

I want my DEA Number Printed on the Sheet

YES

For Security Purposes you will be asked to give us your license numbers
when we contact you to verify your information.

Color of Paper: You will be able to choose the color of paper (Blue, Green, Yellow, Pink) when you "check out" below.

First Line of Copy: Either Doctor's
Name or Practice Name

Second Line of Copy: Either Doctor's
Specialty or Practice Specialty.
(Or anything else you want to say)

WATERMARK:
Tell us what words you want watermarked
on the prescription sheet.

ORDER YOUR MEDICAID APPROVED
HAND WRITTEN PRESCRIPTION SHEETS

Chicago WaterMark Company

Personalized Paper
Distinctive
Affordable
Secure

You will receive an Email Proof BEFORE we ship your order.

IS THIS PART OF A COMBINATION
ORDER WITH ANOTHER DOCTOR?

IF YES, EACH DOCTOR MUST
COMPLETE AN ORDER FORM.
(We have to keep the License Numbers straight)

YOUR PRICING DISCOUNT WILL BE
GIVEN AT THE END OF THE ORDER.

109 Years of Experience