3000 S. Ridgeland Avenue
Berwyn, IL 60402
800-323-9268
fax: 708-749-0171
prco@physiciansrecord.com
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Custom Form
Chart Dividers
Bound Book
Booklet
Quote Request Form
Custom Form Quotation
Quantities:
Size:
Name of Form:
Number of Parts in Form:
Form is (check one): Continuous Snap-out Other:
Form is (check one): NCR Carbon-Interleaved
Marginal Words: Yes No
Color of Ink: PMS Color:
Are all parts printed the same? Yes No If no, explain:
Camera-Ready Copy Supplied: Yes No
Numbered Forms: Yes No If yes, what is the starting number?
Account Number:
Facility Name:
Contact Person:
Address:
City: State: Zip Code: Country:
Phone Number: Ext: Fax Number:
Email Address:
Comments:
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Chart Divider Quotation
Chart dividers are sold as sets or as individual tabs. Please tell us which you'd like a price quote on:
Tabs at Right: Tabs at Bottom:
Paper: 36 lb. buff ledger 36 lb. white ledger 200 lb. white Kimdura (tear-proof) Other:
Printing: Tabs - 1 Side Tabs - 2 Sides
Punching: No Punching 2 Hole Punched - 1/4" round holes 3 Hole Punched - 1/4" round holes 5 Hole Punched - 1/4" round holes Other:
Mylar Reinforced Holes: Yes No
Bound Book Quotation
Title of Book:
Quantities (Check all that apply): 1 2 3 4 5 Other:
Size: 12 1/4" X 9" 14" X 11" 17" X 11" Other:
Number of Pages: 100 Single Pages (Single Page Spread) 200 Single Pages 300 Single Pages 100 Folio Pages (Double Page Spread) 200 Folio Pages 300 Folio Pages Other:
Number of Entries Per Page: 20 25 30 Other:
Booklet Quotation
Size: 8 1/2 X 11 5 1/2 X 8 1/2 Other:
Saddle Stitched
Perfect Binding
Number of Pages (Including Cover):
Stock: Inside Sheets: Cover:
Ink (Inside Sheets): 1 Color 2 Colors Ink (Cover): 1 Color 2 Colors
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