Patient Encounter Form Pre-printed with your information, includes blank spaces to add your own Diagnostic Codes.

• Snap Apart Form - Glued Top
• Printed in Black Ink3 Parts - White, Canary & Pink
• 8-1/2" x 5 1/2"
• 500 per pack
• Personalization includes- Includes your imprinted practice name, address, and phone number, up to 5 lines. 3-part form provides a patient copy and a 2-hole punched permanent record.

FREIGHT CHARGES
ACS always confirms to our customers total amount to be charged including freight costs before order
is processed.

RETURNS
There is a 15 day return policy. Customers have 15 days to return products after they have received them. Products are not returnable after this time. Returns are subject to a restocking fee of 25%. If the return is a result of our error, we will issue a call tag. We grant returns on products only if the product and the packaging are in re-sellable condition. Custom products are not returnable.

SALES TAX
ACS charges sales tax if you are a Texas resident, Texas State Sales Tax will be added at the time your
order is invoiced. If you are tax exempt you must provide a Texas Sales Tax Exemption Certificate.