2015-2016 Dental Reference Guide

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EXCUSE SLIPS AND PRESCRIPTION PADS

DHPI can customize your prescriptions pads. Ask your account manager for details .

Family Dental Center 444 South Monroe Fremont, Wisconsin 54222 555-222-0000

FORMS

FORM #3373

Front

Front

Excuse Slips and Prescription Pads Concerned over the problems associated with counterfeiting and forgery of prescription forms? Did you know that several state health agencies now outline specific guidelines for issuance of prescription forms for Schedule II controlled substances. 4-1/4" x 5-1/2", 50# blue offset copy proof paper. Hidden VOID image. Excuse Pads Contains: 3 pads of 50 sheets per pad. 792-3373 Each .................................... $8.95

Prescription Pads Contains: 5 pads of 50 sheets per pad. 792-NOTEPAD Each ................................... $43.25

Printed on security watermark paper to prevent fraud

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