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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.

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Visit the Tutorials tab to learn more.

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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

CheckboxLidocaine HCl 5 mg Oral Troche

Add

Adding

Radio 3

CheckboxLidocaine HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxKetotifen Fumarate 0.05%/Metronidazole 0.75% Topical Cream

Add

Adding

Radio 3

CheckboxLidocaine 5%/Nitoglycerin 0.2% Rectal Ointment

Add

Adding

Radio 3

CheckboxLidocaine 2%/Prilocaine 1.5%/Tetracaine 4% Topical Cream

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 90.4 mcg/Liothyronine 27.4 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine 1%/Nitroglycerin 0.2% Rectal Ointment

Add

Adding

Radio 3

CheckboxLidocaine HCl 2%/Misoprostol 0.0024%/Triamcinolone Acetonide 0.1% Topical Lotion

Add

Adding

Radio 3

CheckboxLiothyronine 35 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine HCl 5% Oral Gel

Add

Adding

Radio 3

CheckboxL-Carnitine 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLevetiracetam 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 75 mcg/Liothyronine 10 mcg Oral Capsules

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 50 mcg/Liothyronine 10 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine 30% Topical Cream

Add

Adding

Radio 3

CheckboxLevetiracetam 250 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine HCl 1%/Nifedipine 0.2% Rectal OIntment

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 10 mcg/Liothyronine 5 mcg/mL Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 7.5 mg/ml/Tetracaine 7.5 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxLiothyronine 2 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 9.5 mcg/Liothyronine 2.25 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine HCl 10% Topical Spray

Add

Adding

Radio 3

CheckboxLidocaine 1.5%/Prilocaine 1.5%/Tetracaine 4% Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine HCl 7%/Tetracaine HCl 7% Transdermal Cream

Add

Adding

Radio 3

CheckboxKetotifen 1 mg Oral Capsules

Add

Adding

Radio 3

CheckboxLiothyronine 5 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLiothyronine 7.5 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLipoic Acid 200 mg Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine 2%/Meloxicam 0.09%/Prilocaine 2%/Topiramate 2.5% Topical Cream

Add

Adding

Radio 3

CheckboxLidocaine 15% Topical Ointment

Add

Adding

Radio 3

CheckboxLorazepam 2 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 60 mcg/Liothyronine 15 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLipoic Acid 100 mg Oral Capsules

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 147 mcg/Liothyronine 3 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLactic Acid 14%/Resorcinol 14%/Salicylic Acid 14% Topical Liquid

Add

Adding

Radio 3

CheckboxLactic Acid 20%/Salicylic Acid 20% Topical Liquid

Add

Adding

Radio 3

CheckboxLetrozole 1 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxLidocaine HCl 10%/Procaine HCl 10% Topical Ointment

Add

Adding

Radio 3

CheckboxLidocaine HCl 23%/Tetracaine HCl 7% Topical Gel

Add

Adding

Radio 3

CheckboxLiothyronine 20 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 15 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLorazepam 0.1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 2%/Morphine Sulfate 2%/Transdermal Cream

Add

Adding

Radio 3

CheckboxL-Arginine 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxL-Arginine 30% Topical Cream

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 19 mcg/Liothyronine 4.5 mcg Oral Capsules

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 20 mcg/mL Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 40 mg/Misoprostol 10 mcg/Naltrexone HCl 10 mcg/Phenytoin Sodium 20 mcg/mL Topical Ointment

Add

Adding

Radio 3

CheckboxLidocaine HCl 10% Topical Cream

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 60 mcg/Liothyronine 30 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine HCl 4%/Phenylephrine HCl 0.25% Otic Liquid

Add

Adding

Radio 3

CheckboxLosartan Potassium 6.25 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxLansoprazole 3 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxLorazepam 1 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxLiothyronine 1 mcg Oral Capsules

Add

Adding

Radio 3

CheckboxLamotrigine 15 mg Oral Capsules

Add

Adding

Radio 3

CheckboxLevothyroxine sodium 20 mcg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 150 mcg/mL Oral Liquid

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 19 mcg/Liothyronine 4.5 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxKetorolac Tromethamine 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine HCl 5%/Meloxicam 0.3%/Topiramate 3% Topical Cream

Add

Adding

Radio 3

CheckboxLactic Acid 88% Topical Liquid

Add

Adding

Radio 3

CheckboxLidocaine 5% Topical Cream

Add

Adding

Radio 3

CheckboxLidocaine 26 mg/Nitroglycerin 2.6 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxLidocaine 7%/Tetracaine 7% Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine HCL 4%/Phenylephrine HCL 1% Nasal Spray

Add

Adding

Radio 3

CheckboxLithium Carbonate 300 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 60 mcg/Liothyronine 15 mcg Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine 23%/Tetracaine 7% Topical Cream

Add

Adding

Radio 3

CheckboxLeucovorin 2.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine HCl 4% Nasal Spray

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 10 mcg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxKetotifen Fumarate 2.76 mg Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine HCl 2%/Misoprostal 0.0024% Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine 10%/Tetracaine 1.3%/Tetracaine HCl 1.3% Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine 20%/Ketoprofen 20% Topical Ointment

Add

Adding

Radio 3

CheckboxKetotifen Fumarate 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 9.5 mcg/Liothyronine 9 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLevetiracetam 500 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxLidocaine 3%/Prilocaine 3%/Tetracaine 4% Topical Cream

Add

Adding

Radio 3

CheckboxLactic Acid 18.75%/Salicylic Acid 18.75% Topical Liquid

Add

Adding

Radio 3

CheckboxLactic Acid 16.5%/Salicylic Acid 16.5% Topical Liquid

Add

Adding

Radio 3

CheckboxLidocaine HCl 10%/Phenylephrine HCl 1%/Tetracaine HCl 5.69% Topical Cream

Add

Adding

Radio 3

CheckboxLiothyronine 15 mcg Oral Capsules

Add

Adding

Radio 3

CheckboxLeflunomide 15 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine HCl 30% Phonotophoresis Gel

Add

Adding

Radio 3

CheckboxLactobacillus Acidophilus 500 millions CFU Vaginal Suppository

Add

Adding

Radio 3

CheckboxLevofloxacin 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLiothyronine 15 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine HCl 4% Oral Rinse

Add

Adding

Radio 3

CheckboxLipoic Acid 300 mg Oral Capsules

Add

Adding

Radio 3

CheckboxLactic Acid 5%/Salicylic Acid 2% Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine 5%/Prilocaine 5% Topical Cream

Add

Adding

Radio 3

CheckboxLamotrigine 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 2%/Meloxiam 0.09%/Prilocaine 2%/Topiramate 2.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 25 mcg/Liothyronine 12.5 mcg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 25 mcg Liothyronine 2 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine HCl 27%/Phenylephrine HCl 0.05%/Tetracaine HCl 7% Topical Cream

Add

Adding

Radio 3

CheckboxLiothyronine 25 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine HCl 5%/Nifedipine 0.5% Rectal Ointment

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.

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