MU Print and Mail Services, University of Missouri

MUHC Prescription Pads

Order Form

Note: This form requires FireFox or Chrome browser to work properly.

Item Sample/Preview

item sample/preview

Item Information

(Items in red are required.)

Specifications

  • 50 sheets per pad
  • White paper with Pantograph non-white background
  • Anti-copy coin-rub on back
  • 5.5" x 4.25"
  • 1-sided only

Questions?
Call Cindy Murray at 882-7801

A - Address/phone:





B - Logo:

C - Department/Phone:

(limited to 80 characters)

D - Physicians/residents/fellows:
Name Title NPI#
1.
2.
3.
4.
5.
6.
**E - DEA#:


**Note: if all of the physicians/residents/fellows printed on the script pad are assigned a DEA number, you can have this # printed on the script pad (see E on the sample). The physician/resident/fellow would then need to write in their assigned four-digit suffix in the blank following the DEA line.

Billing Information

(Items in red are required.)


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Note: You can use pull down menu above to fill in the fiscal officer email if you know their name and they are included in the list. If they are not in the list, you can still enter their email address manually.

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*This person will also receive order confirmation.

End of MUHC Prescription Pads Order Form

MU Print and Mail Services, University of Missouri