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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

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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

CheckboxTopiramate 5 mg/ml to 40 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTacrolimus 0.15% Topical Ointment

Add

Adding

Radio 3

CheckboxTacrolimus 0.1% Topical Shampoo

Add

Adding

Radio 3

CheckboxTheanine 250 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTramadol HCl 20% Topical Gel

Add

Adding

Radio 3

CheckboxThyroid 150 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxTramadol HCl 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxThyroid 120 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxTobramycin Sulfate 1% Otic Liquid

Add

Adding

Radio 3

CheckboxSumatriptan 100 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxTerbutaline Sulfate 2.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTestosterone 200 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxSulfasalazine 500 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxTacrolimus 0.05% Topical Ointment

Add

Adding

Radio 3

CheckboxTacrolimus 2 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxTea Tree Oil 5% Topical Ointment

Add

Adding

Radio 3

CheckboxTerazosin 0.5 mg/2 mL Oral Liquid

Add

Adding

Radio 3

CheckboxTramadol HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxTheophylline 100 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxTacrolimus 0.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTizanidine 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTetracycline HCl 3% Topical Ointment

Add

Adding

Radio 3

CheckboxSulfanilamide 15% Vaginal Cream

Add

Adding

Radio 3

CheckboxTacrolimus 0.1% Oral Rinse Liquid

Add

Adding

Radio 3

CheckboxTramadol HCL 5 mg/0.1 mL Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxThiamine HCl 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTestosterone 3 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxTerbinafine HCl 2.5% Nail Liquid

Add

Adding

Radio 3

CheckboxSulfur 6% Topical Ointment

Add

Adding

Radio 3

CheckboxThioridazine HCl 100 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSumatriptan 25 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxTemazepam 15 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxTerazosin 1 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxTizanidine 2 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxTacrolimus 0.15% Topical Cream

Add

Adding

Radio 3

CheckboxTheophylline 30 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxThyroid 30 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxSulfur 6% Topical Cream

Add

Adding

Radio 3

CheckboxTestosterone 100 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxTacrolimus 1.5 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxTheophylline 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTopiramate 6 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTheophylline 5 µg/0.1 mL Nasal Spray

Add

Adding

Radio 3

CheckboxTheophylline 25 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxThymol 4% Topical Liquid

Add

Adding

Radio 3

CheckboxThyroid 97.5 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxTetracycline HCl 5.4% Mouthwash Liquid

Add

Adding

Radio 3

CheckboxSumatriptan 50 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxTheanine 25 mg/0.1 mL Oral Spray

Add

Adding

Radio 3

CheckboxTacrolimus 1 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxTetracycline HCl 125 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTetracycline HCl 250 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxTestosterone 150 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxTerbinafine HCl 2% Nail Liquid

Add

Adding

Radio 3

CheckboxTerbinafine 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTetracaine HCl 0.5% Oral Rinse

Add

Adding

Radio 3

CheckboxTacrolimus 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTetracycline HCl 5% Topical Paste

Add

Adding

Radio 3

CheckboxThyroid 75 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxTolterodine Tartrate 2 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxTetracycline HCl 60 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTopiramate 25 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxTacrolimus 2 mg/5 mL Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxTacrolimus 0.1% Topical Foam

Add

Adding

Radio 3

CheckboxTerbinafine 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTheophylline 50 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxTamoxifen Citrate 6 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSulfasalazine 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxThyroid 60 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxTramadol HCl 20 mg/0.1 mL Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxThymol 3% Topical Liquid

Add

Adding

Radio 3

CheckboxTramadol hydrochloride 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTinidazole 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTea Tree Oil 5%/Terbinafine 2%/Undecylenic Acid 22.5% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxThyroid 90 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxTadalafil 25 mg/ml Oral Sublingual Drops

Add

Adding

Radio 3

CheckboxTetracaine HCl 4% Topical Cream

Add

Adding

Radio 3

CheckboxTemozolomide 420 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxTobramycin 15 mg/ml Ophthalmic Liquid (Fortified)

Add

Adding

Radio 3

CheckboxTestosterone 0.5 mg Vaginal Suppostories

Add

Adding

Radio 3

CheckboxSuccimer 250 mg Oral Capsules (DMSA)

Add

Adding

Radio 3

CheckboxSodium Thiosulfate 20%/Zinc Oxide 20% Topical Ointment

Add

Adding

Radio 3

CheckboxSalicyclic Acid 60% Topical Paste

Add

Adding

Radio 3

CheckboxPyrilamine Maleate 2.5% Topical Ointment

Add

Adding

Radio 3

CheckboxSodium Benzoate 500 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSodium Hyaluronate 200 mg Oral Troches

Add

Adding

Radio 3

CheckboxPyrogallol 10% Topical Cream

Add

Adding

Radio 3

CheckboxRutin 200 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSodium Benzoate 3 g/15 mL Oral Liquid

Add

Adding

Radio 3

CheckboxQuetiapine Fumarate 10 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 50% Topical Paste

Add

Adding

Radio 3

CheckboxSalicylic Acid 4% Topical Foam

Add

Adding

Radio 3

CheckboxRamipril 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSodium Benzoate 333.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSalicylic Acid 10% Topical Cream

Add

Adding

Radio 3

CheckboxSodium Thiosulfate 25% Topical Liquid

Add

Adding

Radio 3

CheckboxSodium Valproate 431 mg Oral Capsules

Add

Adding

Radio 3

CheckboxResorcinol 0.585%/Sulfur 4% Topical Lotion

Add

Adding

Radio 3

CheckboxSildenafil 50 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxPyridoxine HCl 25 mg/ml Oral Liquid

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.