Rx Security Order Manager

NEW ORDER PAGE

(Fields marked with a red * are required)

* State/Province:

Are you a Member of any of the following Associations/Groups?:

* Member ID:

Contact Info

* Name:

* Phone:

Fax:

* Email:

* Authorizing Prescriber Name:

* Authorizing License or DEA Number:

Enter your contact information above to receive correspondence from Rx Security with respect to any present and future billing and ordering. Your contact information will not be shared with anyone else or used for any other purpose.

Providers & Locations

Number of Providers

Number of Locations

* Enter data in fields below exactly how you would like them to appear on your script. Press "Preview Design" button below to refresh the design with any changes.

Providers

Prov. 1

Locations

Loc. 1

Order Info

* Product Type:

Alternative Footer Image:

* Quantity (and price):

* Please note: the total charge shown will not include sales tax (if any) - as applicable to your region

* Shipping Type:

* Orders shipping to Alaska or Hawaii will incur additional shipping fees

To imprint prescriber/location information check here:

* If your software already prints this information, please leave the checkbox blank

Shipping Info

* Name:

* Address Line 1:

Address Line 2:

* City:

* State/Province:

* Zip/Postal Code:

Billing Info

* Name:

* Address Line 1:

Address Line 2:

* City:

* State/Province:

* Zip/Postal Code:

Payment Info

Please note that transactions on American Express credit cards may intially show as "STRIPE" on your credit card statement. This is the name of our trusted payment processing company. This will usually revert back to "Rx Security" after approximately 48 hours.

* Credit Card Type:

* Credit Card Number:

* Name on Credit Card:

* Credit Card Expiry :

* CVC:

Additional Comments

* Please Note that though the design shown may not be an exact representation, its purpose is to give you as accurate an impression as is possible using the data you entered above. Be assured that the pad will be compliant with all regulations applicable to the state (or province) that it is printed for. If you wish to receive a more accurate representation before it is printed, please request a Design Proof to be forwarded to you by specifying such in the Additional Comments section above.