California Security EMR Laser Order Form

A RUSH can be applied at any time and will be shipped in 3-5 business days for a fee. You can find the order confirmation sent via e-mail. View pricing here

By law we have to ship Controlled Substance Rx Scripts to an address that does appear on the providers CA Medical and/or DEA license. We also do not ship to P.O. Boxes.

California Security EMR Laser Order Form

Please attach, email or fax copy of your EMR sample.

Add Files:

Need Proof (Optional)

To add multiple providers or locations, please scroll down to the bottom of the order form.

Practice Name

Yes (Print on Pad)

State License Number

DEA License Number

State Exp. Date

DEA Exp. Date

NPI Number

Yes (Print on Pad)

Address

City

State

Zipcode

Phone

Fax:

Yes (Print on Pad)

Contact Name

Contact Email

Contact Phone

** By law we have to ship Controlled Substance Rx Scripts to an address that does appear on the providers CA Medical and/or DEA license. We also do not ship to P.O. Boxes.**

Shipping Address (If Different)

Shipping Method

Payment Method

Rush Order? (Extra fee applies)

Prescription Type:

Prescription Format

Quantity

Multiple Providers

Multiple Locations