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1

Search for medications or formulations to prescribe.

2

Click Order Medication and fill out order form.

3

Print and fax it to the pharmacy at 401-284-4506.

Need help?

Visit the Tutorials tab to learn more.

First

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1

Circle for steps.

Patient Information

Last Name

First Name

MI

Address

Apt. #

City

State

ZIP

Phone #

Date of Birth

Sex

Male

Female

Email

Patient will pick up at pharmacy

Please ship to patient

Please ship to office

2

Circle for steps.

Prescriber and Prescription Information

Prescriber's First Name

Prescriber's Last Name

Phone Number

Fax Number

Address

City

State

ZIP

NPI/DEA

Add

Adding

Radio 3

CheckboxZonisamide 200 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxZiprasidone Mesylate 2 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxZinc Sulfate Heptahydrate 1 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxZinc Oxide 20% Topical Gel

Add

Adding

Radio 3

CheckboxZinc Chloride 4% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Chloride 0.5% Oral Solution

Add

Adding

Radio 3

CheckboxZinc Chloride 0.2% Resorcinol 5% Salicylic Acid 0.1% Topical Lotion

Add

Adding

Radio 3

CheckboxZinc Acetate Dihydrate 16.8 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxZinc 2% Otic Solution

Add

Adding

Radio 3

CheckboxXylitol 1 g Troches

Add

Adding

Radio 3

CheckboxVoriconazole 40 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxVitamin E 600 I.U. Rectal/Vaginal Suppositories

Add

Adding

Radio 3

CheckboxVerapamil Hydrochloride 40 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxVitamin A Palmitate 150000 IU Rectal Suppositories

Add

Adding

Radio 3

CheckboxVancomycin Hydrochloride 2% Vaginal Gel

Add

Adding

Radio 3

CheckboxVancomycin HCl 20 mg/g Silver Sulfadiazine 1% Topical Cream

Add

Adding

Radio 3

CheckboxValsartan 2 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxValsartan 16 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxTrilostane 5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxTrichloroacetic Acid 10% to 50% Topical Solution

Add

Adding

Radio 3

CheckboxTriamcinolone Acetonide 1 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxTriamcinolone Acetonide 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxTriamcinolone Acetonide 0.05% Topical Lotion

Add

Adding

Radio 3

CheckboxTriamcinolone 8 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxTriamcinolone 1 mg/mL Otic Solution

Add

Adding

Radio 3

CheckboxTretinoin 10 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxTretinoin 5 mg Capsules

Add

Adding

Radio 3

CheckboxTretinoin 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxTorsemide 5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxTolterodine Tartrate 0.4 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxTobramycin Sulfate 10 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxTimolol Maleate 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxThiothixene Hydrochloride 2 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxThiamine Hydrochloride 100 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxTheophylline 75 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxThiabendazole 150 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxTheophylline 20 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxTetracycline Hydrochloride 250 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxTetracycline Hydrochloride 250 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxTheophylline 2% Topical Ointment

Add

Adding

Radio 3

CheckboxTetracaine Hydrochloride 2% Oral Solution

Add

Adding

Radio 3

CheckboxTetracaine 50 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxTerbinafine Hydrochloride 50 mg/mL Nail Solution

Add

Adding

Radio 3

CheckboxTerbinafine 40 mg/mL Topical Solution

Add

Adding

Radio 3

CheckboxTerbinafine 10 mg/g Urea 200 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxTemozolomide 10 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxTemazepam 30 mg/0.5 mL Topical Gel

Add

Adding

Radio 3

CheckboxTea Tree Oil 6% Topical Cream

Add

Adding

Radio 3

CheckboxTea Tree Oil 5% Vitamin E 30 IU/g Topical Cream

Add

Adding

Radio 3

CheckboxTea Tree Oil 200 mg Vaginal Suppositories

Add

Adding

Radio 3

CheckboxTea Tree Oil 2% Otic Drops

Add

Adding

Radio 3

CheckboxTea Tree Oil 10% Topical Ointment

Add

Adding

Radio 3

CheckboxTea Tree Oil 1% Topical Gel

Add

Adding

Radio 3

CheckboxTannic Acid 7% Topical Solution

Add

Adding

Radio 3

CheckboxTannic Acid 50% Oral Solution

Add

Adding

Radio 3

CheckboxTannic Acid 5% Urea 3% Zinc Gluconate 2% Topical Ointment

Add

Adding

Radio 3

CheckboxTannic Acid 20% Topical Ointment

Add

Adding

Radio 3

CheckboxTannic Acid 10% Topical Gel

Add

Adding

Radio 3

CheckboxTannic Acid 180 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxTamsulosin Hydrochoride 0.2 mg Capsules

Add

Adding

Radio 3

CheckboxTamoxifen 10 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxTacrolimus 0.5 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxTacrolimus 0.3% Topical Ointment

Add

Adding

Radio 3

CheckboxSulindac 200 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxSulfur 10% Topical Ointment

Add

Adding

Radio 3

CheckboxSulfasalazine 50 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxSulfadiazine 100 mg/mL Trimethoprim 20 mg/mL Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxSqualene 0.2% Topical Cream

Add

Adding

Radio 3

CheckboxSotalol Hydrochloride 5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxSodium Benzoate 250 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxSirolimus 2 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxSimvastatin 1 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxSildenafil Citrate 10 mg/g Vaginal Gel

Add

Adding

Radio 3

CheckboxSildenafil 10 mg/mL Nasal Spray

Add

Adding

Radio 3

CheckboxRisperidone 4 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxRisperidone 1 mg/0.5 mL Topical Gel

Add

Adding

Radio 3

CheckboxRifampin 100 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxRifampin 1% Nasal Drops

Add

Adding

Radio 3

CheckboxRifampin 10 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxRiboflavin 5 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxRiboflavin 10 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxRibavirin 40 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxRibavirin 200 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxResveratrol 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxResorcinol 50% Topical Paste

Add

Adding

Radio 3

CheckboxResorcinol 2% Zinc Oxide 24% Topical Paste

Add

Adding

Radio 3

CheckboxResorcinol 2% Sulfur 5% Topical Gel

Add

Adding

Radio 3

CheckboxResorcinol 10% Topical Cream

Add

Adding

Radio 3

CheckboxResorcinol 1% Salicylic Acid 3% Topical Gel

Add

Adding

Radio 3

CheckboxPyrimethamine 16.7 mg/mL Sulfadiazine Sodium 333 mg/mL Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxPyridostigmine Bromide 6 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxPyrantel 50 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxPropylthiouracil 100 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxPropranolol Hydrochloride 20 mg/mL Sublingual Solution

Add

Adding

Radio 3

CheckboxPropranolol Hydrochloride 20 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxPropranolol Hydrochloride 10 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxPropranolol Hydrochloride 10 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxPropranolol Hydrochloride 0.5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxPropafenone Hydrochloride 1.5 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxPromethazine Hydrochloride 2.5 mg/mL Rectal Gel

Directions:

QTY:

Refills

1

2

3

4

5

6

7

8

9

10

xPrescriber's Signature:

Date

3

Circle for steps.

Fill out the Pharmacy Name and Fax Number, then fax it to the Pharmacy.

Pharmacy Name

Pharmacy Fax Number

You may need to scale up or down your order form when printing to make it fit the page.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.