Prescription Writer
 Order Form
Please FAX  form to 405-755-8999  
Prescription Writer Version

Price

 Setup Postage & Handling

Total

indicate choice
 (X)

 Ordering Instructions:

Version sm

   $86 $35 $8.00 $129   

1.Print form by clicking on the 
                     
    symbol on the tool bar 
         (2 pages will print)

2. Fill out both pages 

3. FAX pages to 405-755-8999
Version mmr

$130

 $50 $8.00 $188   
Orders for Oklahoma Residents will have 7.875% tax added
Name: .
Address: .
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expires:  __ __/__ __  (mo/yr)
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expires:  __ __/__ __  (mo/yr)
I authorize Okdrs.com or its representative to charge the above amount
Name on card:___________________________ Signature:___________________

 

 

 

 

Page 2

Name(s) to appear in prescription form header:
Address to appear in prescription form header:
Phone # s to appear in prescription form header:
Other Information to appear in  header (Optional):
DEA number to appear on prescription form (Optional):
Where did you hear about this software product?

Contact Telephone Number:  (__ __ __) __ __ __- __ __ __ __

Contact e-mail address:          _________________________________________________