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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

CheckboxNaloxone HCl 0.04 mg/Oxycodone HCl 40 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxNaproxen 500 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxOmeprazole 10 mg/Sucralfate 1000 mg/15 mL Oral Liquid

Add

Adding

Radio 3

CheckboxNicotinic Acid 250 mg/5 mL Topical Lotion

Add

Adding

Radio 3

CheckboxNystatin 100 000 IU/mL Oral Rinse

Add

Adding

Radio 3

CheckboxNaproxen 440 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxNifedipine 0.2% Rectal Ointment

Add

Adding

Radio 3

CheckboxOmeprazole 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxNystatin 2% Nasal Spray

Add

Adding

Radio 3

CheckboxNifedipine 32.5 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxNicotinamide Adenine Dinucleotide Oxidized 200 mg Oral Capsules

Add

Adding

Radio 3

CheckboxNeomycin 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxOmeprazole 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxNifedipine 0.3% Rectal Ointment

Add

Adding

Radio 3

CheckboxNifedipine 8%/Pentoxifylline 8% Topical Gel

Add

Adding

Radio 3

CheckboxMupirocin 2% Nasal Spray

Add

Adding

Radio 3

CheckboxNystatin 100 000 UI/mL/Triamcinolone Acetonide 0.1% Oral Rinse

Add

Adding

Radio 3

CheckboxNadolol 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxNitrofurantoin 75 mg Oral Capsules

Add

Adding

Radio 3

CheckboxNaproxen 250 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxNicotinamide Adenine Dinucleotide Oxidized 25 mg Sublingual Troches

Add

Adding

Radio 3

CheckboxNaloxone HCl 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMycophenolate Mofetil 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMupirocin 0.2%/Triamcinolone Acetonide 0.03%/Xylitol 2% Nasal Spray

Add

Adding

Radio 3

CheckboxNystatin 200 000 IU Oral Troches

Add

Adding

Radio 3

CheckboxNaproxen Sodium 500 mg/Sumatriptan 85 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxNaproxen Sodium 10% Transdermal Cream

Add

Adding

Radio 3

CheckboxNadolol 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMupirocin 2%/Gentamicin 2% Topical Ointment

Add

Adding

Radio 3

CheckboxNitrofurantoin 25 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxNiacinamide 5%/Phytonadione 1%/Tretinoin 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxOndansetron HCl Dihydrate 0.4 mg/0.1 mL Topical Cream

Add

Adding

Radio 3

CheckboxNystatin 1 MU Oral Capsules

Add

Adding

Radio 3

CheckboxMorphine Sulfate 20 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Tretinoin 0.01% Topical Foam

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.025%/Spironolactone 3% Topical Liquid

Add

Adding

Radio 3

CheckboxMiconazole 2% Nasal Liquid

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Tretinoin 0.01% Topical Liquid

Add

Adding

Radio 3

CheckboxMorphine Sulfate 100 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxMetronidazole 1000 mg/60 mL Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxMinoxidil 7% Topical Liquid

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Tretinoin 0.025% Topical Foam

Add

Adding

Radio 3

CheckboxMethimazole 50 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxMethylcobalamin 6.25 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxMinoxidil 7%/Tretinoin 0.01% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 10% Topical Liquid

Add

Adding

Radio 3

CheckboxMethylprednisolone 4 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxMethylcobalamin 20 mg/ml Injection

Add

Adding

Radio 3

CheckboxMinoxidil 8%/Tretinoin 0.01% Topical Lotion

Add

Adding

Radio 3

CheckboxMetoprolol Tartrate 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMethocarbamol 250 mg Oral Capsules

Add

Adding

Radio 3

CheckboxMometasone Furoate 10 mg/ml Nasal Irrigation Liquid

Add

Adding

Radio 3

CheckboxMetronidazole 2% Topical Cream

Add

Adding

Radio 3

CheckboxMethylsulfonylmethane 20% Nasal Spray

Add

Adding

Radio 3

CheckboxMinoxidil 3%/Tretinoin 0.025% Topical Foam

Add

Adding

Radio 3

CheckboxMethimazole 5%/Tranexamic Acid 10% Topical Cream

Add

Adding

Radio 3

CheckboxMorphine Sulfate 2% Topical Spray

Add

Adding

Radio 3

CheckboxMetronidazole 50 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxMethocarbamol 200 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMetoprolol Tartrate 3 mg/0.5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxMiconazole 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMetronidazole 10% Topical Ointment

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Nifedipine 2%/Phenytoin 5% Topical Cream

Add

Adding

Radio 3

CheckboxMethimazole 2.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMethylsalicylate 30% Topical Liquid

Add

Adding

Radio 3

CheckboxMorphine Sulfate 5 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxMiconazole 2% Oral Paste

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.01%/Triamcinolone Acetonide 0.1% Topical Liquid

Add

Adding

Radio 3

CheckboxMetronidazole 500 mg/ml Topical Spray

Add

Adding

Radio 3

CheckboxMethimazole 20 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxMethylcobalamin 4 mg Oral Troches

Add

Adding

Radio 3

CheckboxMontelukast Sodium 5.2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMetoclopramide HCl 1.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxMetronidazole 2%/Misoprostol 0.0024%/Phenytoin 5% Topical gel

Add

Adding

Radio 3

CheckboxMirtazapine 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMirtazapine 3.25 mg/0.5 mL Transdermal Gel

Add

Adding

Radio 3

CheckboxMilk Thistle 44 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Spironolactone 3% Topical Foam

Add

Adding

Radio 3

CheckboxMidodrine HCl 0.2% Topical Cream

Add

Adding

Radio 3

CheckboxMorphine Sulfate 1 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxMethimazole 3 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxMinoxidil 5.5% Topical Foam

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Nifedipine 2%/Phenytoin Sodium 5% Topical Ointment

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Phenytoin 5% Topical gel

Add

Adding

Radio 3

CheckboxMinocycline 1% Topical Ointment

Add

Adding

Radio 3

CheckboxMinoxidil 1.8 mg Oral Troches

Add

Adding

Radio 3

CheckboxMometasone Furoate 0.6 mg/ml/Tobramycin 125 mg/ml Nasal Gel

Add

Adding

Radio 3

CheckboxMetoclopramide 10 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxMiconazole 2% Nasal Spray

Add

Adding

Radio 3

CheckboxMisoprostol 30 mcg/mL Oral Liquid

Add

Adding

Radio 3

CheckboxMorphine Sulfate 0.15% Topical Cream

Add

Adding

Radio 3

CheckboxMetronidazole 25 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxModafinil 5 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxMinoxidil 15.0% Topical Foam

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.025%/Spironolactone 3% Topical Foam

Add

Adding

Radio 3

CheckboxMinoxidil 8% Topical Foam

Add

Adding

Radio 3

CheckboxMetronidazole Benzoate 5%/Mupirocin 5% Topical Cream

Add

Adding

Radio 3

CheckboxMethimazole 75 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxMetoclopramide HCl 2.4% Transdermal Gel

Add

Adding

Radio 3

CheckboxMethylcobalamin 25 mg/ml Nasal Spray

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.