Phone: 800-356-8141
Fax: 800-356-2356
service@sycom.com

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California Controlled Substance Prescription Blanks Order Form

To Order:

Complete the form below (one per prescriber). When complete, click "ENTER" to view the printable version. Print the completed form. After printing the form, you MUST:

Collect signatures from all prescribers (if more than one prescriber on blank)
Designate a single prescriber responsible for shipment
Complete all payment and billing information
Send your order via Fax or mail to Sycom.

Mail your order to:
301 Grove Road
Thorofare, NJ 08086

Fax your order to:
800-356-2356

Questions: Contact our Prescription Blank Specialist at 800-356-8141.

NOTE: IMPORTANT INFORMATION FOR ALL CALIFORNIA CONTROLLED SUBSTANCE RX BLANK ORDERS!

All orders and reorders for California Controlled Substance Prescription Blanks must be submitted in writing via mail or fax.
Use one Order Form per prescription blank order. Multiple prescriber names and one address may be printed on the front of each prescription blank. (Additional addresses may be printed on the back for an additional cost.)
The address used for shipping must match the DEA registration's authorized prescribers or health care facilities.
License number and category of licensure must be provided for each prescriber or facility.
Copy of each perscriber's DEA registration must be included for all orders and reorders.
The signature of each authorized prescriber or health care facility representative must be provided with each order.

Step #1

Select a vertical or horizontal format:

Horizontal CA280-1

Vertical CA270-1

Click to enlarge

Indicate if you would like consecutive numbering to start with a number other than zero:

No Yes

Enter start number

Select a quantity (50 blanks per pad)

10 Pads $69.95
20 Pads $129.95

40 Pads $239.95
50 Pads $289.95

Step #2

Enter the information to be printed on the prescription blanks EXACTLY as you would like it to appear.
All fields with an * are required.

Practice or Facility Name (if to be printed on Rx):

*Prescriber:

*Degree:

Practice or Specialty (if to be printed below prescriber name):

*License #:

*DEA #:

*Category of Licensure:

*Address to be printed:

*City:

*State:

*Zip Code:

*Telephone # to be printed with area code:

Fax # (if to be printed on Rx):

Step #3

Enter shipping information (must be official address on file with DEA).

Street Address:

City:

State:

Zip Code:

Step #4

Enter any additional prescribers. NOTE: Signatures required on printed order form for prescribers listed below.

Prescriber Name:

License #:

Category of Licensure:

DEA #:

Prescriber Name:

License #:

Category of Licensure:

DEA #:

Prescriber Name:

License #:

Category of Licensure:

DEA #:

Prescriber Name:

License #:

Category of Licensure:

DEA #:

Optional

Additional address(es) to be printed on the back of the prescription blanks for an additional charge. (Must have phone number with area code.)

Street Address:

City:

State:

Zip Code:

Telephone #:

Street Address:

City:

State:

Zip Code:

Telephone #:

Street Address:

City:

State:

Zip Code:

Telephone #:

Street Address:

City:

State:

Zip Code:

Telephone #:

You have now completed your online Rx ordering form. Please review the information then click ENTER to view the printable form. The printed form must be mailed or faxed to Sycom for processing.