To order PAPrx software, fax this completed form to (512) 306-1926

Date:

PAPrx Order Form

Shipping Information*

Company: *______________________________________________________________

Contact Name/Title: * _______________________________________________________________

Address 1: * _____________________________________________________________________

Address 2: ______________________________________________________________________

City State Zip: * __________________________________________________________________

Phone: * _______________________________________________________________________

Fax: * _________________________________________________________________________

Email: _________________________________________________________________________

Billing Information (if different)

Company: *______________________________________________________________

Contact Name/Title: * _______________________________________________________________

Address 1: * _____________________________________________________________________

Address 2: ______________________________________________________________________

City State Zip: * __________________________________________________________________

Phone: * _______________________________________________________________________

Fax: * _________________________________________________________________________

Email: _________________________________________________________________________

* - required

Number of Rx’s Ordered:

*Circle one Clinic or Hospital 200\$200

Private individual 1000\$1000 Order

If Texas add 8.5% Sales Tax Tax:

If Tax-exempt, please include exemption form.

No Sales Tax Necessary Outside Texas Total:

Hours per week currently spent filling out PAP forms: ___________________

Number of patients per month that qualify for PAP programs: ____________________

Patient Assistance Program Rx

PO Box 161711

Austin, TX 78716

(512) 306-1780 fax (512) 306-1926 www.PAPrx.com