Order Form Builder | Technician Dashboard | Bayview Pharmacy | Your Compounding Pharmacy of Choice

Home

Prescribe

Your Order Form

Compound Catalog Popular Order Forms

Staff

Compound Catalog

Order Form w/ Formulas

Custom Order Form Popular Order Forms Send Order Forms Documents Hospice Peptides Assessments

Prescribers

Tutorials

Settings

My Account Support Log Out

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

Optimized for desktop use.
Please view on a larger screen to use this tool.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

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

CheckboxPromethazine Hydrochloride 1.25 mg/0.1 mL Nasal Spray

Add

Adding

Radio 3

CheckboxProgesterone 75 mg Vaginal Suppositories

Add

Adding

Radio 3

CheckboxPromethazine Hydrochloride 1 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxProchlorperazine 5 mg/0.1mL Nasal Spray

Add

Adding

Radio 3

CheckboxPrednisolone Sodium Phosphate 10 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxProchlorperazine 20 mg/0.5 mL Topical Gel

Add

Adding

Radio 3

CheckboxPrazosin Hydrochloride 0.25 mg/0.1 mL Topical Gel

Add

Adding

Radio 3

CheckboxPramoxine Hydrochloride 25 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxPovidone Iodine 5 mg Troches

Add

Adding

Radio 3

CheckboxPovidone Iodine 200 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxPovidone Iodine 10% Topical Solution

Add

Adding

Radio 3

CheckboxPotassium Nitrate 10% Topical Gel

Add

Adding

Radio 3

CheckboxPovidone Iodine 10% Topical Gel

Add

Adding

Radio 3

CheckboxPotassium Iodide 16 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxPotassium Iodide 100 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxPotassium Chloride 1 mmol/mL Oral Solution

Add

Adding

Radio 3

CheckboxPodophyllum Resin 20% Topical Gel

Add

Adding

Radio 3

CheckboxPodophyllum Resin 10% Salicylic Acid 25% Topical Solution

Add

Adding

Radio 3

CheckboxPodophyllum Resin 1% Salicylic Acid 3% Topical Solution

Add

Adding

Radio 3

CheckboxPodophyllum 25% Topical Solution

Add

Adding

Radio 3

CheckboxPiroxicam 40 mg Troches

Add

Adding

Radio 3

CheckboxPilocarpine Hydrochloride 10 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxPilocarpine Hydrochloride 1.25 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxPilocarpine Hydrochloride 0.2 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxPhenytoin 6 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxPhenytoin 5% Topical Ointment

Add

Adding

Radio 3

CheckboxPhenytoin 2% Lidocaine 6% Topical Powder

Add

Adding

Radio 3

CheckboxPhenol 3% Otic Solution

Add

Adding

Radio 3

CheckboxPhenol 0.2% Zinc Oxide 12% Topical Paste

Add

Adding

Radio 3

CheckboxPhenobarbital 9 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxPhenobarbital 70 mg Capsules

Add

Adding

Radio 3

CheckboxPhenobarbital 50 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxPhenobarbital 22 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxPhenobarbital 15 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxPerphenazine 0.5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxPergolide Mesylate 0.5 mg Capsules

Add

Adding

Radio 3

CheckboxPergolide Mesylate 1 mg Capsules

Add

Adding

Radio 3

CheckboxPentoxifylline 20 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxPentobarbital Na 45 mg Pyrilamine Maleate 50 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxPentobarbital Na 25 mg Pyrilamine Maleate 23 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxPentobarbital Na 100 mg Pyrilamine Maleate 50 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxPapaverine Hydrochloride 30 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxOxycodone Hydrochloride 25 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxOxycodone Hydrochloride 10 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxOrphenadrine Citrate 5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxOrphenadrine Citrate 20 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxOndansetron Hydrochloride 8 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxOndansetron Hydrochloride 0.8 mg/mL Oral Suspension (Gluten Free)

Add

Adding

Radio 3

CheckboxNystatin 6.62 mg/mL Triamcinolone Acetonide 0.43 mg/mL Topical Lotion

Add

Adding

Radio 3

CheckboxNystatin 50000 Units/mL Nasal Solution

Add

Adding

Radio 3

CheckboxNystatin 20000 Units/g Sucralfate 200 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxNitrofurantoin 2 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxNifedipine 10 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxNicotine Tartrate 6 mg/100 mL Rectal Enema

Add

Adding

Radio 3

CheckboxNicotine Tartrate 6 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxNeomycin Sulfate 25 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxNeomycin Sulfate 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxNaratriptan Hydrochloride 0.5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxNaproxen 25 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxNaproxen 20% Topical Gel

Add

Adding

Radio 3

CheckboxNaltrexone Hydrochloride 25 mg Capsules

Add

Adding

Radio 3

CheckboxNaltrexone Hydrochloride 1 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxNaltrexone Hydrochloride 1 mg/mL Nasal Solution

Add

Adding

Radio 3

CheckboxNalbuphine Hydrochloride 10 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxMycophenolate Mofetil 20 mg/mL Topical Cream

Add

Adding

Radio 3

CheckboxMupirocin 20 mg Vaginal Suppositories

Add

Adding

Radio 3

CheckboxMupirocin 2% Nasal Ointment

Add

Adding

Radio 3

CheckboxMupirocin 1% Nasal Suspension

Add

Adding

Radio 3

CheckboxMorphine Sulfate 5 mg/0.1 mL Nasal Spray

Add

Adding

Radio 3

CheckboxMoxifloxacin 20 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxMorphine Sulfate 10 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxMorphine Sulfate 10 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxMometasone Furoate 20 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxMometasone Furoate 10 mg/mL Topical Lotion

Add

Adding

Radio 3

CheckboxMisoprostol 24 µg/g Phenytoin 50 mg/mL Topical Cream

Add

Adding

Radio 3

CheckboxMisoprostol 2.66 µg/g Topical Powder

Add

Adding

Radio 3

CheckboxMisoprostol 0.024 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxMisoprostol 0.024 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxMisoprostol 0.024 mg/mL Lidocaine HCl 10 mg/mL Topical Solution

Add

Adding

Radio 3

CheckboxMisoprostol 0.024 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxMirtazapine 15 mg/0.5 mL Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 5%/ Retinoic Acid 0.01% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 1 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxMinocycline Hydrochloride 250 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxMinocycline 5 mg Troches

Add

Adding

Radio 3

CheckboxMiconazole 2% Tolnaftate 1% Topical Solution

Add

Adding

Radio 3

CheckboxMiconazole 2% Boric Acid Otic Powder

Add

Adding

Radio 3

CheckboxMiconazole 10% Topical Cream

Add

Adding

Radio 3

CheckboxMiconazole 10 mg/mL Nasal Solution

Add

Adding

Radio 3

CheckboxMiconazole 1% Tolnaftate 1% Topical Lotion

Add

Adding

Radio 3

CheckboxMetronidazole Benzoate 80 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxMetronidazole 500 mg/60 ml Rectal Enema

Add

Adding

Radio 3

CheckboxMetronidazole 20 mg/mL/Misoprostol 24 µg/mL/Phenytoin 50 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxMetronidazole 20 mg/mL/Misoprostol 0.024 mg/mL/Phenytoin 50 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxMetronidazole 20 mg/g/Misoprostol 24 µg/g/Pentoxifylline 50 mg/g Topical Ointment

Add

Adding

Radio 3

CheckboxMetronidazole 100 mg/g Topical Ointment

Add

Adding

Radio 3

CheckboxMetronidazole 10% Zinc Oxide 2% Topical Gel

Add

Adding

Radio 3

CheckboxMetronidazole 10 mg/g/Silver Sulfadiazine 10 mg/g Topical Ointment

Add

Adding

Radio 3

CheckboxMetronidazole 10 mg/g/Phenytoin 50 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxMetolazone 1 mg/mL Oral Suspension

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.