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Printable Order Form

 

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Printable Order Form   (Zpf)
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Description: If you prefer to print and send in your order you can do so using the printable form below.
Form ID: Zpf
File(s): Secure RX Order Form
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    Pricing Info:

    Download Printable Order Form


    Single-Part Standard-Size Pads

    No. of
    Pads
    No. of
    Scripts
    Price
    Per Pad
    Total
    Price
    1
    100
    $53.90
    $53.90
    4
    400
    $19.95
    $79.80
    5
    500
    $16.85
    $84.25
    8
    800
    $13.30
    $106.40
    10
    1000
    $10.90
    $109.00
    20
    2000
    $9.95
    $199.00
    25
    2500
    $9.90
    $247.50
    40
    4000
    $6.95
    $278.00
    50
    5000
    $6.90
    $345.00
    60
    6000
    $6.80
    $408.00
    80
    8000
    $6.65
    $532.00

    Two-Part Standard-Size Pads

    No. of
    Pads
    No. of
    Scripts
    Price
    Per Pad
    Total
    Price
    1
    50
    $66.55
    $66.55
    4
    200
    $26.00
    $104.00
    5
    250
    $21.80
    $109.00
    8
    400
    $15.15
    $121.20
    10
    500
    $13.30
    $133.00
    20
    1000
    $10.40
    $208.00
    25
    1250
    $10.30
    $257.50
    40
    2000
    $8.70
    $348.00
    50
    2500
    $8.60
    $430.00
    60
    3000
    $8.50
    $510.00
    80
    4000
    $8.00
    $640.00

    Single-Part Large Size Pads

    No. of
    Pads
    No. of
    Scripts
    Price
    Per Pad
    Total
    Price
    1
    100
    $78.65
    $78.65
    5
    500
    $36.30
    $181.50
    10
    1000
    $23.60
    $236.00
    20
    2000
    $16.40
    $328.00
    25
    2500
    $16.30
    $407.50
    40
    4000
    $13.25
    $530.00
    50
    5000
    $12.50
    $625.00

    Two-Part Large-Size Pads

    No. of
    Pads
    No. of
    Scripts
    Price
    Per Pad
    Total
    Price
    1
    50
    $90.75
    $90.75
    5
    250
    $42.35
    $211.75
    10
    500
    $24.80
    $248.00
    20
    1000
    $17.80
    $356.00
    25
    1250
    $17.70
    $442.50
    40
    2000
    $14.60
    $584.00
    50
    2500
    $13.75
    $687.50

    Laser & Ink Jet Compatible Forms

    No. of
    Forms
    Total
    Price
    100
    $95.70
    500
    $156.20
    1000
    $240.90
    2500
    $482.90
    5000
    $845.90
    10000
    $1,208.90
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