2015-2016 Dental Reference Guide

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FORM #3373
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.
Each .................................... $8.95
Prescription Pads
Contains: 5 pads of 50 sheets per pad.
Each ................................... $43.25
Front Front
DHPI can customize your prescriptions pads. Ask your account manager for details.
Family Dental Center
444 South Monroe
Fremont, Wisconsin 54222
555-222-0000
EXCUSE SLIPS AND PRESCRIPTION PADS
Printed on security
watermark paper to
prevent fraud