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

Please fill out the information which you want to print on the pad.

Thank you for your order! You can find the order confirmation sent via e-mail.

Medicaid EMR Laser Prescription Order Form

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