Maine Identification Signature Form

All prescription orders for the State of Maine must be accompanied by a signature, date, and printed name of one of the prescribers printed on the pad. If blank stock, the signature must match the provider's DEA that was supplied to us on the order. Please fill out the form below. You may also click here to download the signature form.

Please Complete This Signature Form:

Prescriber First Name:

Prescriber Last Name:

Prescriber Email:

Order Number:

Are you the prescriber?