Sprint Quality Printing, Inc. : ORDER Prescription Forms

This order form is for use by Healthcare Practitioners and Institutions authorized to purchase
tamper-resistant prescription forms in Delaware.

Please Enter All Information Correctly, THIS is what will be printed on your forms.

Note: You will receive one proof to verify all information before printing.

Practice Name (optional)

Prescriber Name *REQUIRED*

Address *REQUIRED*

Address 2 (eg. Professional Center)

Suite Number (if applicable)

City, State, Zip *REQUIRED*

Phone Number *REQUIRED*

Fax Number

E-mail Address *REQUIRED*

Security Code (assigned by DPR) *REQUIRED*

License # *REQUIRED*

DEA # (optional)

Pad Format *REQUIRED*

Pad Style *REQUIRED*

Start Number (must be 5 digits, eg: 00001) *REQUIRED*

Number of Pads Ordered

Delivery *REQUIRED*

Additional Details (additional charges may apply)

Please provide additional details about your prescription forms in the field below.

If you would like to have your "Logo" printed on your forms, please attach your file here. (Files accepted are: eps, tiff, jpg or pdf.)

Filename