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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

CheckboxGlycolic Acid 60% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 6%/Ketoprofen 20%/Lidocaine 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 5%/Salicylic Acid 1% Topical Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 20%/Kojic Acid 5%/Salicylic Acid 20% Topical Liquid

Add

Adding

Radio 3

CheckboxGlycopyrrolate 2% Topical Liquid

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Ibuprofen 5%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 15%/Lidocaine HCl 3% Transdermal Gel

Add

Adding

Radio 3

CheckboxGabapentin 6%/Meloxicam 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxGlycopyrrolate 0.4 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxGlucosamine HCl 10%/Ketoprofen 15% Transdermal Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 14% Topical Liquid

Add

Adding

Radio 3

CheckboxGabapentin 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Indomethacin 10%/Lidocaine HCl 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 70%/Hydroquinone 7%/Tretinoin 0.04%/Triamcinolone Acetonide 0.05% Topical Liquid

Add

Adding

Radio 3

CheckboxGlutathione 250 mg Oral Capsules

Add

Adding

Radio 3

CheckboxGlutathione 500 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxGabapentin 50 mg/ml Xylitol Free Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxGabapentin 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxGlycolic Acid 10% Topical Liquid

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketoprofen 20%/Lidocaine HCl 5% Topical Cream

Add

Adding

Radio 3

CheckboxGlycolic Acid 10% Topical Cream

Add

Adding

Radio 3

CheckboxGabapentin 6% Transdermal Gel

Add

Adding

Radio 3

CheckboxGentamicin 0.2%/Lidocaine HCl 5%/Misoprostol 0.0024%/Phenytoin 5% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 450 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxGlycerin 20%/Minoxidil 8%/Tretinoin 0.01% Topical Liquid

Add

Adding

Radio 3

CheckboxGluconolactone 4%/Glycolic Acid 10%/Kojic Acid 2.5%/Lactic Acid 5% Topical Cream

Add

Adding

Radio 3

CheckboxGlutathione 150 mg Sublingual Troches

Add

Adding

Radio 3

CheckboxGabapentin 5%/Ketoprofen 5%/Lidocaine 5%/Pentoxifylline 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxGabapentin 10%/Lidocaine HCl 5%/Tramadol HCl 5% Topical Cream

Add

Adding

Radio 3

CheckboxGabapentin 6%/Lidocaine HCl 5%/Meloxicam 0.5%/Orphenadrine Citrate 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxGlycerin 10%/Salicylic Acid 5%/Urea 25% Topical Cream

Add

Adding

Radio 3

CheckboxGlycolic Acid 2%/Tretinoin 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxGlutamine 1.25 g Rectal Suppository

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Pentoxifylline 8% Transdermal Gel

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Ibuprofen 5%/Ketoprofen 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 5% Topical Cream

Add

Adding

Radio 3

CheckboxGentamicin 80 mg/1000 mL Nasal Irrigation Liquid

Add

Adding

Radio 3

CheckboxGlutamine 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxGlipizide 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxGabapentin 10%/Nifedipine 2% Transdermal Cream

Add

Adding

Radio 3

CheckboxGabapentin 100 mg Oral Troche

Add

Adding

Radio 3

CheckboxGabapentin 5%/Loperamide HCl 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxGabapentin 300 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxGlyburide 10 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxGlipizide 5 mg Oral Tablets (Gluten Free)

Add

Adding

Radio 3

CheckboxGlycolic Acid 2%/Salicylic Acid 5%/Tretinoin 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxGlycopyrrolate 2 mg/ml Oral Drops

Add

Adding

Radio 3

CheckboxGabapentin 4% Rectal Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 20%/Hydroquinone 7%/Tretinoin 0.04%/Triamcinolone Acetonide 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxGreen Tea Extract 150 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketamine HCL 11.5%/Ketoprofen 5%/Lidocaine HCL 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxGentamicin Sulfate 0.2%/Misoprostol 0.0024%/Phenytoin 5%/Pentoxifylline 5% Topical Cream

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketoprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxGentamicin 0.3% Otic Liquid

Add

Adding

Radio 3

CheckboxGabapentin 4%/Ketamine 2.5%/Ketoprofen 4%/Lidocaine 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxGabapentin 300 mg/10 mL Oral Liquid

Add

Adding

Radio 3

CheckboxGlycopyrrolate 0.5% Topical Liquid

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketamine 7%/Ketorolac Tromethamine 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 25% Topical Cream

Add

Adding

Radio 3

CheckboxGlycerin 10%/Lactic Acid 5%/Urea 25% Topical Ointment

Add

Adding

Radio 3

CheckboxGabapentin 5%/Ketoprofen 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 70% Topical Liquid

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketamine HCl 11.5%/Ketoprofen 10%/Lidocaine HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 70% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 6%/Mometasone Furoate 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxGlycine 500 mg Oral Capsules

Add

Adding

Radio 3

CheckboxGlycolic Acid 8% Topical Liquid

Add

Adding

Radio 3

CheckboxGentamicin 1.7%/Miconazole 2% Otic Liquid

Add

Adding

Radio 3

CheckboxGlutathione 10 mg/Tranexamic Acid 100 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxGlycolic Acid 20%/Tretinoin 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxGabapentin 250 mg Oral Troche

Add

Adding

Radio 3

CheckboxGlycopyrrolate 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxGlycopyrrolate 1.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketamine 10%/Ketoprofen 10%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxGabapentin 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxGabapentin 6%/Indomethacin 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketamine HCL 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketoprofen 15%/Lidocaine HCl 5%/Menthol 5% Topical Cream

Add

Adding

Radio 3

CheckboxGlutathione 250 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxGlutathione 15%/Niacinamide 2%/Tranexamic Acid 10% Topical Cream

Add

Adding

Radio 3

CheckboxGlycolic Acid 8% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 10% Topical Gel

Add

Adding

Radio 3

CheckboxGuanfacine 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxGabapentin 25 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxGabapentin 6%/Ketoprofen 10%/Lidocaine 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Ketoprofen 10%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxGabapentin 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxGlycopyrrolate 1% Topical Spray

Add

Adding

Radio 3

CheckboxGentamicin 1 mg/gm Topical Cream

Add

Adding

Radio 3

CheckboxGlycerin 10%/Urea 25%/Zinc Oxide 5% Topical Ointment

Add

Adding

Radio 3

CheckboxGabapentin 2.5%/Ketamine HCl 11.5%/Lidocaine HCl 2% Topical Cream

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Minoxidil 5%/Tretinoin 0.025% Topical Liquid

Add

Adding

Radio 3

CheckboxFolic Acid 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxFluocinonide 0.05%/Ketoconazole 2%/Salicylic Acid 10% Topical Shampoo

Add

Adding

Radio 3

CheckboxFentanyl 50 mcg/mL Sublingual Drops

Add

Adding

Radio 3

CheckboxFluconazole 4%/Ibuprofen 4% Nail Lacquer

Add

Adding

Radio 3

CheckboxFluconazole 2% Topical Nail Liquid

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Minoxidil 3%/Spironolactone 5% Topical Liquid

Add

Adding

Radio 3

CheckboxFluconazole 3%/Itraconazole 3%/Terbinafine HCl 1%/Urea 30% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxFluoxetine HCl 11.2 mg/ml Transdermal Gel (Vet)

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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