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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.

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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

CheckboxKetorolac Tromethamine 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLorazepam 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 2%/Meloxicam 0.1%/Prilocaine 2%/Topiramate 2%/Tramadol HCl 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxLidocaine HCl 120 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxLubiprostone 8 µg/mL Oral Liquid

Add

Adding

Radio 3

CheckboxLactic Acid 15%/Salicylic Acid 15%/Trichloroacetic Acid 8% Topical Liquid

Add

Adding

Radio 3

CheckboxLidocaine 1.5%/Nifedipine 0.3% Rectal Ointment

Add

Adding

Radio 3

CheckboxLidocaine 2%/Nitroglycerin 0.125% Rectal Ointment

Add

Adding

Radio 3

CheckboxLidocaine 15%/Prilocaine 5% Topical Cream

Add

Adding

Radio 3

CheckboxLidocaine 20%/Phenylephrine 2%/Tetracaine 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 78 mcg/Liothyronine 15.5 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 15 mcg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 10%/Phenylephrine HCl 0.25%/Prilocaine 10% Topical Cream

Add

Adding

Radio 3

CheckboxLorazepam 0.5 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 0.2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLiothyronine 30 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLoxapine Succinate 6.8 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 1.042%/Meloxicam 0.1%/Tizanidine HCl 0.4% Topical Cream

Add

Adding

Radio 3

CheckboxKetorolac Tromethamine 15.75 mg/Lidocaine HCl 50 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxLiothyronine 1 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLactobacillus Acidophilus 150 millions CFU/g Vaginal Cream

Add

Adding

Radio 3

CheckboxL-Lysine HCl 250 mg Oral Capsules

Add

Adding

Radio 3

CheckboxLevetiracetam 60 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 3%/Metronidazole 2%/Phenytoin Sodium 5% Topical Ointment

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 5 mcg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 2%/Metronidazole 2%/Misoprostol 0.0024% Topical Ointment

Add

Adding

Radio 3

CheckboxLidocaine 15%/Prilocaine HCl 5.83% Topical Ointment

Add

Adding

Radio 3

CheckboxLiothyronine 10 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLevetiracetam 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine 5%/Salicylic Acid 60% Topical Paste

Add

Adding

Radio 3

CheckboxLactic Acid 18%/Salicylic Acid 18% Topical Paste

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 40 mcg/mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxLorazepam 0.5 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxLanzoprazole 7.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine HCl 2%/Misoprostol 0.003%/Phenytoin 2.5 Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine 4% Topical Gel

Add

Adding

Radio 3

CheckboxLorazepam 1 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxLidocaine HCl 4%/Phenylephrine HCl 1% Nasal Drops

Add

Adding

Radio 3

CheckboxLorazepam 4 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLiothyronine 7.5 mcg Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine 3%/Phenytoin Sodium 5%/Sucralfate 20% Topical Ointment

Add

Adding

Radio 3

CheckboxLidocaine 2.34%/Phenol 1.79%/Tannic Acid 6.25% Rectal Ointment

Add

Adding

Radio 3

CheckboxLiothyronine 7.5 mcg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxLabetalol HCl 40 mg/ml Oral Liquid

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxLidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxLevothyroxine Sodium 88 mcg/5mL Oral Liquid

Add

Adding

Radio 3

CheckboxLiothyronine 7.5 mcg/mL Transdermal Gel

Add

Adding

Radio 3

CheckboxLidocaine 5%/Tetracaine 2.5% Topical Ointment

Add

Adding

Radio 3

CheckboxLidocaine 1%/Triamcinolone Acetonide 0.05%/Zinc Oxide 10% Topical Ointment

Add

Adding

Radio 3

CheckboxLecithin 300 mg Oral Capsules

Add

Adding

Radio 3

CheckboxLidocaine HCl 2%/Metronidazole 2%/Misoprostol 0.0024% Topical Ointment

Add

Adding

Radio 3

CheckboxLithium Carbonate 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxLidocaine HCl 5%/Nifedipine 0.2% Topical Cream

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxKojic Acid 3% Topical Liquid

Add

Adding

Radio 3

CheckboxLidocaine 6%/Tetracaine 4% Topical Ointment

Add

Adding

Radio 3

CheckboxLiothyronine 5 mcg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxKetoprofen 20%/Lidocaine 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetamine 11.5%/Lidocaine HCl 10%/Methocarbamol 10% Topical Gel

Add

Adding

Radio 3

CheckboxIsosorbide Dinitrate 5mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxKetoconazole 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxKetoprofen 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxIbuprofen 2%/Tea Tree Oil 5%/Terbinafine HCl 2% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Minoxidil 2%/Salicylic Acid 1% Topical Liquid

Add

Adding

Radio 3

CheckboxKetoprofen 20%/Lidocaine HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Ketoprofen 10%/Lidocaine 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 28.75 mg Oral Troche

Add

Adding

Radio 3

CheckboxIbuprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxKetoconazole 0.4% Otic Liquid

Add

Adding

Radio 3

CheckboxKetamine 5%/Gabapentin 4%/Amitriptyline 4% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Piroxicam 1% Transdermal Gel

Add

Adding

Radio 3

CheckboxItraconazole 150 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Salicylic Acid 2% Topical Shampoo

Add

Adding

Radio 3

CheckboxIbuprofen 5%/Menthol 3% Topical Gel

Add

Adding

Radio 3

CheckboxIbuprofen 2%/Ketoconazole 2%/Miconazole 2% Topical Liquid

Add

Adding

Radio 3

CheckboxKetoprofen 5% Iontophoresis Liquid

Add

Adding

Radio 3

CheckboxIbuprofen 200 mg/ml Transdermal Cream

Add

Adding

Radio 3

CheckboxKetamine HCL 5.75%/Lidocaine HCL 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetamine HCL 10 mg/Ketoprofen 150 mg/Piroxicam 5 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxIbuprofen 2%/Ketoconazole 2% Nail Liquid

Add

Adding

Radio 3

CheckboxKetoprofen 15%/Lidocaine HCl 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetoconazole 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxIodine Lugol's 30% Topical Liquid

Add

Adding

Radio 3

CheckboxIodoquinol 140 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxIndomethacin 10%/Ketamine HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 50 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxKetoconazole 2% Otic Liquid

Add

Adding

Radio 3

CheckboxKetoprofen 15% Transdermal Gel

Add

Adding

Radio 3

CheckboxItraconazole 100 mcg/mL Oral Rinse

Add

Adding

Radio 3

CheckboxKetamine HCL 10/Ketoprofen 10/Magnesium Chloride 10 Transdermal Gel

Add

Adding

Radio 3

CheckboxIndomethacin 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Cyclobenzaprine HCl 3% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 11.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetoprofen 130 mg/Lidocaine 130 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxIbuprofen 2%/Itraconazole 1% Topical Nail Liquid

Add

Adding

Radio 3

CheckboxKetoconazole 1% Topical Lotion

Add

Adding

Radio 3

CheckboxIbuprofen 10% Transdermal Gel

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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