* Prescriber’s name  & Degree

* Practice Telephone no w/area code

* Practice Contact Name

Facility Provider# (Only if Facility format NJPB)

* Practice Street address

* Practice address - City State Zip

Practice Fax no w/area code

* Prescriber’s License no

* Prescriber’s NPI no

Prescriber’s DEA no (prints only if requested)

No of pads

4

8

12

20

32

Cost

$25.39

$13.42

$11.06

$9.29

$7.30

No of pads

4

8

12

20

32

Cost

$28.99

$15.35

$12.02

$10.30

$8.30

Collaborating MD Name & Degree

Collaborating MD License No.

* Practice name, if any

If multiple MD’s (up to 4) are required on the NJPB - complete the information below

Prescriber’s 2 License no

Prescriber’s 2 NPI no

Prescriber’s 3 License no

Prescriber’s 3 NPI no

Prescriber’s 4 License no

Prescriber’s 4 NPI no

* Practice Contact email address

If an APN or PA format - List the collaborating MD information as well

To complete your order:

Select from the drop down menus below. Scroll for proper quantity and Format

Hit the submit button and a proof will be sent prior to printing

For quantities not listed or - please contact us at info@regencygraphics.com

NJPB Pricing - All pricing shown is Per Pad (no additional cost for shipping)

         Single Sheet NJPB - 100 sheets per pad                                 2-Part NJPB - 50 sheets per pad


No of pads

4

8

12

20

32

Cost

$21.06

$11.61

$9.13

$7.20

$5.86

      Single Sheet NJPB, 2 sided - 100 sheets per pad           2-Part NJPB, 2 sided - 50 sheets per pad


Laser Sheet NJPB, price per lot - 250 at $ 110.745   500 at $144.9    1000 at $178.02       2000 at 270.15

No of pads

4

8

12

20

32

Cost

$24.46

$17.90

$11.06

$8.43

$7.32

Prescriber’s 3 name  & Degree

Prescriber’s 2 name  & Degree

Prescriber’s 4 name  & Degree

To complete order, press submit button below

FILL IN THE FIELDS SHOWN BELOW AND HIT THE SUBMIT BUTTON.

A completed proof will be returned to you prior to printing to insure accuracy

If you need help - contact us at info@regencygraphics.com

Fields marked with an * must be completed


NJPB ORDER FORM