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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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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

CheckboxKetoprofen 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Lidocaine 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxIodoquinol 200 mg Oral Capsules

Add

Adding

Radio 3

CheckboxIbuprofen 1% Iontophoresis Liquid

Add

Adding

Radio 3

CheckboxIodine 3% Oral Liquid

Add

Adding

Radio 3

CheckboxKetamine 15% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Terbinafine HCl 1% Topical Cream

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Piroxicam 3% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 15%/Lidocaine HCl 4% Nasal Spray

Add

Adding

Radio 3

CheckboxKetoprofen 15%/Lidocaine HCl 2%/Menthol 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxIbuprofen 400 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxKetamine 5%/Ketoprofen 15% Transdermal Gel

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxKetamine HCl 172.5 mg Oral Rapid Dissolve Tablets

Add

Adding

Radio 3

CheckboxKetoconazole 2% Minoxidil 0.25% Topical Cream

Add

Adding

Radio 3

CheckboxInositol 500 mg Oral Capsules

Add

Adding

Radio 3

CheckboxImatinib 50 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxImipramine HCl 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxIvermectin 10 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxKetoconazole 1%/Urea 38% Topical Cream

Add

Adding

Radio 3

CheckboxKetamine HCl 2.3%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxIsosorbide Mononitrate 12 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxIvermectin 0.08% Topical Liquid

Add

Adding

Radio 3

CheckboxKetoconazole 100 mg/ml Oral Oil Liquid

Add

Adding

Radio 3

CheckboxKetamine HCl 11.5% Topical Spray

Add

Adding

Radio 3

CheckboxKetoprofen 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetorolac Tromethamine 0.5%/Lidocaine 1% Topical Ointment

Add

Adding

Radio 3

CheckboxKetoprofen 30% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetoconazole 4% Topical Foam

Add

Adding

Radio 3

CheckboxIvermectin 1% Oral Liquid

Add

Adding

Radio 3

CheckboxKetoprofen 20%/Lidocaine 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxIbuprofen 2%/Ketoconazole 2%/Salicylic Acid 10%/Tea Tree Oil 0.5%/Urea 40% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxIndomethacin 5%/Piroxicam 1% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 100 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxIchthammol 20% Topical Ointment

Add

Adding

Radio 3

CheckboxKetoprofen 10% Phonotophoresis Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10 mg Oral Capsules

Add

Adding

Radio 3

CheckboxIrbesartan 150 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxItraconazole 2%/Mupirocin 5%/Tobramycin 5% Topical Ointment

Add

Adding

Radio 3

CheckboxIodoquinol 250 mg/3 mL Oral Liquid

Add

Adding

Radio 3

CheckboxKetamine HCl 34.5 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxKetamine HCl 15%/Lidocaine 10%/Morphine HCl 3% Transdermal Gel

Add

Adding

Radio 3

CheckboxIbuprofen 600 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxKetoconazole 2% Nasal Liquid

Add

Adding

Radio 3

CheckboxIbuprofen 10%/Lidocaine HCl 5% Topical Cream

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Neomycin 0.5% Topical Paste

Add

Adding

Radio 3

CheckboxKetoprofen 30%/Lidocaine 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxItraconazole 10 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Magnesium Chloride 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxItraconazole 2%/Tobramycin 5%/Vancomycin 5% Topical Ointment

Add

Adding

Radio 3

CheckboxKetoprofen 30% Transdermal Gel

Add

Adding

Radio 3

CheckboxItraconazole 0.2%/Mupirocin 0.2%/Triamcinolone Acetonide 0.03% Nasal Spray

Add

Adding

Radio 3

CheckboxIndomethacin 60 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxKetoconazole 4 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Spironolactone 5% Topical Cream

Add

Adding

Radio 3

CheckboxKetamine HCl 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxIndomethacin 100 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxItraconazole 200 mg/ml Nail Liquid

Add

Adding

Radio 3

CheckboxIndomethacin 25 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxKetoprofen 15%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Lidocaine HCl 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxIvermectin 1%/Metronidazole 0.75% Topical Cream

Add

Adding

Radio 3

CheckboxKetoprofen 20%/Ibuprofen 2.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxIbuprofen 160 mg Oral Popsicles

Add

Adding

Radio 3

CheckboxIndomethacin 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxItraconazole 1%/Levofloxacin 2%/Mupirocin 2% Topical Ointment

Add

Adding

Radio 3

CheckboxKetamine HCl 3 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Ketoconazole 2%/Metronidazole 0.75% Topical Cream

Add

Adding

Radio 3

CheckboxHydrocortisone 2.5%/Lidocaine 2%/Nifedipine 3% Rectal Ointment

Add

Adding

Radio 3

CheckboxHaloperidol 2 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxHydroquinone 16% Topical Cream

Add

Adding

Radio 3

CheckboxHydrocortisone 1% Ear Drops

Add

Adding

Radio 3

CheckboxHeparin 1000 Units/mL Injection

Add

Adding

Radio 3

CheckboxHydromorphone HCl 4 mg Oral Troche

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Hydroquinone 8%/Kojic acid 2%/Tretinoin 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxHydrocortisone 2%/Lidocaine HCl 2%/Miconazole Nitrate 3% Topical Gel

Add

Adding

Radio 3

CheckboxHydroxyurea 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxHeparin 14000 units Oral Sublingual Troche

Add

Adding

Radio 3

CheckboxHydrocortisone 0.05%/Vitamin E Acetate 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxHydrocortisone 2.5%/Lidocaine 2%/Pramoxine HCL 2% Rectal Cream

Add

Adding

Radio 3

CheckboxHyaluronic Acid Sodium 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxHydroquinone 6%/Desonide 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxHydroquione 8% Topical Gel

Add

Adding

Radio 3

CheckboxHydroquinone 6%/Salicylic Acid 2%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxHydroquinone 6%/Hydrocortisone 0.5%/Kojic Acid 3%/Vitamin E 1% Topical Cream

Add

Adding

Radio 3

CheckboxHydroquinone 8%/Tretinoin 0.01% Topical Gel

Add

Adding

Radio 3

CheckboxHydrocortisone Acetate 50 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxHydrocortisone 0.55%/Silicone 12.5%/Vitamin E 0.5% Topical Liquid

Add

Adding

Radio 3

CheckboxHydrocortisone 0.9 g/Testosterone 0.45 g/Vitamin A 50/000 IU/Vitamin E 1.8 g/90 g Topical Cream

Add

Adding

Radio 3

CheckboxHydroxyzine HCl 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxHydrocortisone 2.5 mg/Lidocaine HCl 38 mg/Nifedipine 0.2 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxHydroquinone 8% Topical Cream

Add

Adding

Radio 3

CheckboxHydroquinone 10% Topical Cream

Add

Adding

Radio 3

CheckboxHeparin 5000 Units/mL Injection

Add

Adding

Radio 3

CheckboxHydrocortisone 13.2 mg/Lidocaine 72 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxHydromorphone HCl 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxHydroquinone 10%/Tretinoin 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Hydroquinone 8%/Tretinoin 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxHydroxyzine HCl 5 mg/0.1 mL Topical Gel

Add

Adding

Radio 3

CheckboxHydroquinone 2%/Tretinoin 0.015% Topical 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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