Texas Department of Public Safety Regulatory Services Division www.dps.texas.gov TEXAS PRESCRIPTION PROGRAM
For DPS Use Only

PRESCRIPTION PAD MAIL-IN ORDER FORM
0
$ 0.00
# OF PADS
PAYMENT AMOUNT Order Submission Prescription pads are $9 per pad (100 prescriptions).

Payment or online payment receipt must accompany order. No refunds or credits. Allow 30 days for delivery.

Online Payment Trace Number PRACTITIONER (Mid-Level Practitioners: Please use RSD-19A) Last Name:
CSR Number: Current Board License Number: Current Federal (DEA) Registration Number:

Online Transaction Date

First Name:

Middle Name:

(IF ANY)

Suffix:

Degree:

Expiration Date: Expiration Date:

State State:

Name, address and registration numbers are printed exactly as they appear on your current DPS Controlled Substances Registration. Enter your primary practice address information below, only if the information has changed.

Business Address:

(Physical Address required, if using PO box.)

City: Business Phone:

State: State

ZIP Code:

County: Print on Prescription Pad



Yes



No

I verify the information provided above is true and correct, and I understand any required fee is non-refundable. I also understand this is an official government record and any missing information and/or false statement made on this document or any other supplement provided to DPS may result in criminal prosecution.

Date:
Authorized Signature of Registrant

,
(Printed Name and Title)

Send Electronically OR 1. Complete form, print, sign and save to your computer. 2. Pay online at https://www.texas.gov/RxPadOrder . Save the receipt to your computer. 3. Go to Contact Us. Select Texas Prescription Program, then select Submit completed prescription pad order form to upload your receipt and completed order form. **Please do not mail a duplicate copy if