SENTARA

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ITEM DESCRIPTION ITEM NUMBER QUANTITY
PER UNIT
UNIT NUMBER
OF UNITS
REQUESTED
Encounter Form (Practice Specific) Varies Per Site
Not Required
Varies Per Site
Not Required
Thousand
Appointment and/or Business Cards
Name on Card: 
*Please email sample of card to orders@farwestprint.com
SENT BC/AC 500 Box
Appointment Cards (Fold-Over)
*Please email sample of card to orders@farwestprint.com
  1000 Box
Chart/ Miscellaneous Labels
List specific label description below in comment section
Varies Varies Box
Deposit Bag (Secure/Tamper Resistant) 53849 200 Pkg.
Envelopes (#10) Regular Site Specific 1000 Thousand
Envelopes (#10) Standard Window Site Specific 1000 Thousand
HCFA 1500 Insurance Claim Form (Rec 02/12)
(Cut Sheet 8.5x11)
103 2500 Box
HIPAA Privacy Sign-In Sheet 4049 250 Box
Labels (Customized)
*Please provide custom information below
Site Specific 500 Roll/Pkg
Letterhead Site Specific 500 Box
Patient/Lab Follow-Up Cards

Site Specific 500 Box
Promotional Items
*Please contact our office
Site Specific 1 Each
Rubber Stamps (Customized)
* Please provide custom information below
Site Specific 1 Each
Rx Pads - Personalized
(Secure/ Tamper Resistant)
Site Specific 100
(min. order 400)
Pad
Rx Paper (Secure/ Tamper Resistant)
8 1/2 x 11 Sheets
3199 500 Pkg.
Window Env. Large
(For HCFA 1500 Claim Form)
G-42 500 Box
Zebra Thermal Labels
Large (3-1/2" x 1-1/2")
3201 6 rolls per Box Box
Zebra Thermal Labels
Small (2-1/8" x 15/16")
5201 6 rolls per Box Box

Other items not listed above or additional comments: (in the box below)

 
Manager/Approving Authority*
Approving Authority Email* @sentara.com
Site/Practice Name*
Cost Center* - -
Delivery Address*
Today's Date
Date Needed*
Person Placing Order*
Phone Number*
Requestor Email*