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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

Last

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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

CheckboxScopolamine Hydrobromide 0.25 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxS-Adenosylmethionine 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSimvastatin 16 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxSelenium 40 µg/mL Oral Liquid

Add

Adding

Radio 3

CheckboxSilicon Dioxide 28 mg/g Topical Ointment

Add

Adding

Radio 3

CheckboxSucralfate 4% Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxSucralfate 1 g/20 mL oral Liquid

Add

Adding

Radio 3

CheckboxSodium Chloride 2.5 mEq/mL Oral Liquid

Add

Adding

Radio 3

CheckboxPyridoxine HCl 1% Topical Cream

Add

Adding

Radio 3

CheckboxSemaglutide 3 mg/mL Sublingual Suspension (SubMagna™ SL HMW)

Add

Adding

Radio 3

CheckboxSemaglutide 2 mg/mL Sublingual Suspension (SubMagna™ SL HMW)

Add

Adding

Radio 3

CheckboxSemaglutide 1 mg/mL Sublingual Suspension (SubMagna™ SL HMW)

Add

Adding

Radio 3

CheckboxSemaglutide 0.75 mg/mL Sublingual Suspension (SubMagna™ SL HMW)

Add

Adding

Radio 3

CheckboxPyridoxal Phosphate 100 mg/Pyridoxine HCl 200 mg Oral Capsules

Add

Adding

Radio 3

CheckboxOxytocin 20 IU/mL Subligual Liquid

Add

Adding

Radio 3

CheckboxPimobendan 10 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPrazosin HCl 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPhenylephrine hydrochloride 1% Otic Drops

Add

Adding

Radio 3

CheckboxOxybuprocaine HCl 0.4%/Phenylephrine HCl 2.5%/Tropicamide 1% Ophthalmic Liquid

Add

Adding

Radio 3

CheckboxPhenobarbital 200 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxOxycodone HCl 20 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxPilocarpine HCl 20 mg Oral Troches

Add

Adding

Radio 3

CheckboxPhytonadione 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 0.02%/Zinc Oxide 5% Topical Ointment

Add

Adding

Radio 3

CheckboxPhosphatidylcholine 300 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPilocarpine HCl 0.1% Ophthalmic Liquid

Add

Adding

Radio 3

CheckboxParomomycin 500 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPregabalin 12.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPotassium Iodide 32 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPentoxifylline 5% Topical Cream

Add

Adding

Radio 3

CheckboxPentoxifylline 40 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPropranolol HCl 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxOxazepam 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPotassium Iodide 130 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPergolide Mesylate 0.2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPotassium Iodide 50%/Terbinafine HCl 1% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxPyridostigmine Bromide 15 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxPregnenolone 25 mg/Progesterone 60 mg/Testosterone 0.5 mg/0.5 mL Topical Cream

Add

Adding

Radio 3

CheckboxPhenobarbital 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPhenoxybenzamine HCl 2.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxParomomycin 7500 mg/50 mL Rectal Liquid Enema

Add

Adding

Radio 3

CheckboxPrednisolone 100 mg/60 mL Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxPrucalopride 0.75 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPotassium Iodide 16 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPantoprazole 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPhenytoin Sodium 100 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 50 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxPregnenolone 100 mg Sublingual Troches

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 50 mg Oral Tablets (Vet)

Add

Adding

Radio 3

CheckboxPotassium Acetate 40 mEq/20 mL Naso Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxParomomycin 150 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxPerphenazine 1 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxPentoxifylline 200 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxPhenobarbital 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPodophyllum 5%/Salicylic Acid 5%/Trichloroacetic Acid 5% Topical Ointment

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 25 mg/ml Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxPhenobarbital 60 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxPregnenolone 100 mg/g Transdermal Cream

Add

Adding

Radio 3

CheckboxPrednisone 75 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxPhenobarbital 30 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxPhytonadione 2% Topical Cream

Add

Adding

Radio 3

CheckboxPilocarpine HCl 2% Oral Rinse

Add

Adding

Radio 3

CheckboxPhentermine HCl 30 mg/Topiramate 25 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxPyrazinamide 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxOxymetazoline HCl 0.5% Topical Lotion

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 50 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxPodophyllum Resin 5%/Salicylic Acid 30% Topical Paste

Add

Adding

Radio 3

CheckboxPyridoxal Phosphate 50 mg/Pyridoxine HCl 100 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxPhenylbutazone 1 g/5 g Oral Paste

Add

Adding

Radio 3

CheckboxPhenobarbital 10 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxPhytonadione 2.5 mg/0.5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxOxycodone HCl 40 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxPenicillamine 125 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxPovidone-Iodine 1% Oral Rinse Liquid

Add

Adding

Radio 3

CheckboxPrazosin HCl 0.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPovidone-Iodine 1% Nasal Spray

Add

Adding

Radio 3

CheckboxPramipexole Dihydrochloride 0.5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxPentosan Polysulfate Sodium 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPodophyllum 5%/Salicylic Acid 5%/Trichloroacetic Acid 5% Topical Liquid

Add

Adding

Radio 3

CheckboxPrimidone 25 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxPergolide Mesylate 0.1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPergolide Mesylate 0.131 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPotassium Iodide 400 mg Oral Capsules

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 37.5 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxProgesterone 0.025%/Spironolactone 0.05% Topical Foam

Add

Adding

Radio 3

CheckboxPhenazopyridine HCl 200 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxPanthenol 5%/Zinc Oxide 5% Topical Ointment

Add

Adding

Radio 3

CheckboxPhenylbutazone 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPregnenolone 37.5 mg/Progesterone 100 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxPhenytoin 30% Topical Cream

Add

Adding

Radio 3

CheckboxPyridoxal 5 Phosphate 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPhenytoin sodium 400 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxPhentermine HCl 37.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxPhenytoin Sodium 300 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 5 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 75 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxPantoprazole 2 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxPilocarpine HCl 0.25% Ophthalmic Liquid

Add

Adding

Radio 3

CheckboxPapaverine HCl 150 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxPhenoxybenzamine HCl 12.5 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!

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