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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

CheckboxSodium Hyaluronate 2% Topical Gel

Add

Adding

Radio 3

CheckboxSpironolactone 12.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSodium Chloride 2% Iontophoresis Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 40% Topical Liquid

Add

Adding

Radio 3

CheckboxRopinirole HCl 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSquaric Acid Dibutylester 2% Topical Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 70% Topical Paste

Add

Adding

Radio 3

CheckboxRivastigmine 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSelegiline HCl 30 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 2%/Trichloroacetic Acid 7% Topical Gel

Add

Adding

Radio 3

CheckboxSelegiline HCl 0.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSodium Butyrate 300 mM/Liter Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxSilver Sulfadiazine 1% Topical Liquid

Add

Adding

Radio 3

CheckboxScopolamine Hydrobromide 0.4 mg Oral Troche

Add

Adding

Radio 3

CheckboxSulfadiazine 400 mg/ml/Trimethoprim 80 mg/ml Equine Oral Liquid

Add

Adding

Radio 3

CheckboxSodium Valproate 500 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxSucralfate 100 mg/ml Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxPyridoxine HCl 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxRonidazole 250 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSalicylic Acid 5%/Spironolactone 5% Topical Cream

Add

Adding

Radio 3

CheckboxS-Adenosylmethionine 200 mg/ml Oral Oil Liquid

Add

Adding

Radio 3

CheckboxSelegiline HCl 2.50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSodium Thiosulfate 300 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSpironolactone 10% Topical Cream

Add

Adding

Radio 3

CheckboxSulfadiazine 100 mg/ml Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxRamipril 1 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 5%/Urea 10% Topical Ointment

Add

Adding

Radio 3

CheckboxSodium Valproate 576 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxSodium Metabisulfite 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSodium Ascorbate 20% Topical Serum

Add

Adding

Radio 3

CheckboxSalicylic Acid 4% Topical Cream

Add

Adding

Radio 3

CheckboxSodium Ascorbate 10% Topical Cream

Add

Adding

Radio 3

CheckboxRonidazole 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxRiluzole 10 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 60% Topical Ointment

Add

Adding

Radio 3

CheckboxQuinidine sulfate 30 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSilver Sulfadiazine 0.5% Otic Liquid

Add

Adding

Radio 3

CheckboxSpironolactone 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSodium Valproate 288 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxSildenafil 0.2% Otic Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 5% Topical Gel

Add

Adding

Radio 3

CheckboxSotalol HCl 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPyrimethamine 0.5 g/Sulfadiazine 10 g/30 mL Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxSalicylic Acid 10% Topical Ointment

Add

Adding

Radio 3

CheckboxSalicylic Acid 15% Topical Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 1%/Sulfur 2% Topical Ointment

Add

Adding

Radio 3

CheckboxSalicylic Acid 2% Topical Foam

Add

Adding

Radio 3

CheckboxSpironolactone 5% Topical Lotion

Add

Adding

Radio 3

CheckboxScopolamine Hydrobromide 0.4 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPyruvic Acid 50% Topical Liquid

Add

Adding

Radio 3

CheckboxSelegiline hydrochloride 30 mg Oral Capsules

Add

Adding

Radio 3

CheckboxRiboflavin 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSodium Hyaluronate 1%/Tretinoin 0.1% Topical Serum

Add

Adding

Radio 3

CheckboxSalicylic Acid 1%/Sulfur 2% Topical Shampoo

Add

Adding

Radio 3

CheckboxScopolamine Hydrobromide 0.2% Nasal Spray

Add

Adding

Radio 3

CheckboxSodium Valproate 5.75% Topical Liquid

Add

Adding

Radio 3

CheckboxSildenafil 1% Iontophoresis Liquid

Add

Adding

Radio 3

CheckboxPyridoxine HCl 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxQuinidine Sulfate 200 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxScopolamine Hydrobromide 0.4 mg/0.1 mL Transdermal Gel

Add

Adding

Radio 3

CheckboxQuetiapine Fumarate 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSertraline HCl 1.12 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSucralfate 200 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 4%/Aluminum Cl 4% Topical Gel

Add

Adding

Radio 3

CheckboxSelegiline HCl 1.25 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSodium Citrate 90 mg/ml/Sodium Lauryl Sulfate 9 mg/ml Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxSpironolactone 5% Topical Cream

Add

Adding

Radio 3

CheckboxRamelteon 8 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxSodium Chloride 4 mEq/mL Oral Liquid

Add

Adding

Radio 3

CheckboxSertraline 1.25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 20%/Triamcinolone 0.1% Topical Ointment

Add

Adding

Radio 3

CheckboxSqualane 25% Otic Drops

Add

Adding

Radio 3

CheckboxSimvastatin 20 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 1%/Sodium Thiosulfate 20% Topical Gel

Add

Adding

Radio 3

CheckboxResorcinol 15% Topical Cream

Add

Adding

Radio 3

CheckboxSalicylic Acid 3%/Urea 20% Topical Lotion

Add

Adding

Radio 3

CheckboxSucralfate 4% Gastric Tube Site Paste

Add

Adding

Radio 3

CheckboxSelegiline HCl 5 mg/0.5 g Transdermal Cream

Add

Adding

Radio 3

CheckboxSodium Ascorbate 10%/Glycolic Acid 10% Topical Serum

Add

Adding

Radio 3

CheckboxRibavirin 200 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSildenafil 20 mg Oral Troches

Add

Adding

Radio 3

CheckboxRifampin 30 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 5% Topical Cream

Add

Adding

Radio 3

CheckboxSodium Citrate 8.8% Oral Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 3%/Benzoic Acid 6% Topical Ointment

Add

Adding

Radio 3

CheckboxRiboflavin 400 mg Oral Capsules

Add

Adding

Radio 3

CheckboxSodium Chloride 1 mEq/mL Oral Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 30% Topical Liquid

Add

Adding

Radio 3

CheckboxSodium Hyaluronate 6 mg/ml Oral Sublingual Drops

Add

Adding

Radio 3

CheckboxScopolamine Hydrobromide 2.5 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxSodium Bicarbonate 84 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSodium Hyaluronate 5 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxSildenafil 1%/Bupivacaine HCl 5% Transdermal Cream

Add

Adding

Radio 3

CheckboxSalicylic Acid 40%/Cimetidine 10%/Fluorouracil 2%/Deoxy-D-Glucose 0.2% Topical Warts Cream

Add

Adding

Radio 3

CheckboxRabeprazole Sodium 20 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxSucralfate 40% Topical Paste

Add

Adding

Radio 3

CheckboxQuetiapine 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSimethicone 40 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSalicylic Acid 40% Topical Paste

Add

Adding

Radio 3

CheckboxSodium Thiosulfate 600 mg/5 mL Gastric Tube 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.