RX Pad Request

Request additional referral pad forms for your practice. We will mail them within 2 business days.

Referral forms: online or PDF

Submit a referral online, or download our blank RX/referral form to print and complete. The PDF includes the referral form and patient instructions.

Submit referral online Download blank RX/referral form (PDF)

2-page PDF. No sign-in or online form submission required to download.

Physician / Contact Name *

Practice / Clinic Name *

Phone *

Format: 555-123-4567

Email *

Attention To *

Shipping Address *

We will mail your referral forms to this address within 2 business days.

Address *

Suite or Unit Number

City *

State *

ZIP *

Special instructions or quantity notes

Optional — specify quantity, pad type, or any other notes.

Supporting Documents (optional)

PDF, JPG, PNG. Up to 25 MB each.

Authorized Signature *

Typing your full name is the keyboard-accessible equivalent to drawing a signature.

Type or draw your full legal name to authorize this request.

Notice at Collection (California)

By submitting this form, you understand that Precise Imaging collects the following categories of personal information:

Identifiers (name, email, phone, address, IP)
Customer records (contact and insurance details)
Professional information (practice or firm details)
Commercial information (services scheduled or requested)
Internet activity (pages viewed, device and browser)

We use this information to:

Mail referral pads and follow up with your practice.
Verify the request and prevent fraud or abuse.
Operate, secure, and improve our websites and request channels.

Retention: Request records are kept for up to 3 years for audit and fraud-prevention purposes, then deleted unless retention is otherwise required by law.

We do not sell your personal information. For full details — including your California privacy rights, our sources and recipients, retention periods, and how to opt out of "sharing" for cross-context behavioral advertising — see our Privacy Policy. Protected health information collected through these channels is also governed by our Notice of Privacy Practices.