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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.

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

CheckboxFluocinolone Acetonide 0.05%/Ketoconazole 1% Oral Rinse

Add

Adding

Radio 3

CheckboxFurosemide 7 mg/0.1 mL Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Minoxidil 3% Topical Liquid

Add

Adding

Radio 3

CheckboxFluoxetine HCl 11.2 mg/ml Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxFluocinolone Acetonide 0.01%/Salicylic Acid 1% Topical Shampoo

Add

Adding

Radio 3

CheckboxFluconazole 5 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Minoxidil 10% Topical Liquid

Add

Adding

Radio 3

CheckboxFluorouracil 2%/Salicylic Acid 17% Topical Liquid

Add

Adding

Radio 3

CheckboxFluconazole 150 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxFluconazole 100 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxFluconazole 1%/Urea 20% Topical Liquid

Add

Adding

Radio 3

CheckboxFludrocortisone Acetate 0.3 mg Oral Capsules

Add

Adding

Radio 3

CheckboxFluocinolone Acetonide 0.05%/Ketoconazole 2%/Salicylic Acid 6% Topical Shampoo

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Minoxidil 3% Topical Foam

Add

Adding

Radio 3

CheckboxFinasteride 2.5%/Minoxidil 5%/Tretinoin 0.025% Topical Foam

Add

Adding

Radio 3

CheckboxFenbendazole 216 mg/ml Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxFluorouracil 5%/Salicylic Acid 30% Topical Liquid

Add

Adding

Radio 3

CheckboxFluoxetine HCl 1 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxFluocinonide 0.01%/Hydroquinone 6%/Tretinoin 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxFinasteride 2.5% Topical Liquid

Add

Adding

Radio 3

CheckboxFinasteride 0.1% Topical Liquid

Add

Adding

Radio 3

CheckboxFamotidine 5 mg/0.1mL Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxFolic Acid 6.6 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxEthambutol HCl 300 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxFluticasone Propionate 0.05%/Itraconazole 2% Topical Gel

Add

Adding

Radio 3

CheckboxFluorouracil 5%/Salicylic Acid 40% Topical Cream

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Minoxidil 5% Topical Liquid

Add

Adding

Radio 3

CheckboxFinasteride 0.1% Minoxidil 5% Topical Foam

Add

Adding

Radio 3

CheckboxExemestane 5 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxFinasteride 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Hydrocortisone 0.1%/Minoxidil 10%/Progesterone 0.25% Topical Lotion

Add

Adding

Radio 3

CheckboxFentanyl Citrate 2 mg Oral Troches

Add

Adding

Radio 3

CheckboxFluconazole 2% Topical Shampoo

Add

Adding

Radio 3

CheckboxFluorouracil 2% Topical Cream

Add

Adding

Radio 3

CheckboxEtodolac 75 mg/2.5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxFluoxetine HCl 4.48 mg/ml Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxFluocinonide 0.05%/Kojic Acid 6%/Tretinoin 0.025% Topical Cream

Add

Adding

Radio 3

CheckboxFamciclovir 5% Topical Ointment

Add

Adding

Radio 3

CheckboxFluocinonide 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxFentanyl Citrate 1 mg Oral Troches

Add

Adding

Radio 3

CheckboxFlecainide Acetate 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxFluocinolone 0.25 mg/g/Neomycin 3.23 mg/g/Nystatin 100000 IU/g Topical Ointment

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Hydrocortisone 1%/Minoxidil 7%/Progesterone 2% Topical Foam

Add

Adding

Radio 3

CheckboxFluocinolone Acetonide 0.1%/Minoxidil 5%/Tretinoin 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxFluocinonide 0.05% Oral Mouth Rinse

Add

Adding

Radio 3

CheckboxFluorouracil 4%/Hyaluronic Acid 2% Topical Cream

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Minoxidil 5%/Tretinoin 0.01% Topical Liquid

Add

Adding

Radio 3

CheckboxFluticasone Propionate 0.05%/Itraconazole 2%/Mupirocin 2%/Urea 20% Topical Gel

Add

Adding

Radio 3

CheckboxFluorouracil 5%/Glycolic Acid 50% Topical Cream

Add

Adding

Radio 3

CheckboxFluocinolone Acetonide 0.02%/Hydroquinone 4%/Tretinoin 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxFinasteride 0.25%/Minoxidil 0.5%/Tretinoin 0.05% Topical Liquid

Add

Adding

Radio 3

CheckboxFolic acid 5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxFluocinonide 0.0167%/Coal Tar 1.67%/Salicylic Acid 2% Topical Gel

Add

Adding

Radio 3

CheckboxFurosemide 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxFluoxetine HCl 22.4 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxFluconazole 1.7%/Ibuprofen 2% Topical Nail Liquid

Add

Adding

Radio 3

CheckboxFamciclovir 125 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxFluconazole 40 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxFinasteride 1.25 mg Oral Capsules

Add

Adding

Radio 3

CheckboxFluorouracil 5%/Salicylic acid 12% Topical Liquid

Add

Adding

Radio 3

CheckboxFlecainide Acetate 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxFinasteride 1 mg/Minoxidil 5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxFluconazole 4% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxFluocinolone acetonide 0.01%/Hydroquinone 4%/Retinoic acid 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxFluocinolone Acetonide 0.01%/Hydroquinone 4%/Kojic Acid 4%/Tretinoin 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxFinasteride 1% Topical Gel

Add

Adding

Radio 3

CheckboxFolic Acid 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxFluoxetine 80 mg Oral Capsules

Add

Adding

Radio 3

CheckboxFluconazole 3%/Itraconazole 3%/Terbinafine HCL 1% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxFluconazole 1%/Itraconazole 1% Topical Nail Liquid

Add

Adding

Radio 3

CheckboxFinasteride 1%/Minoxidil 10%/Tretinoin 0.01% Topical Liquid

Add

Adding

Radio 3

CheckboxFinasteride 0.25%/Hydrocortisone 1%/Minoxidil 8%/Tretinoin 0.01% Topical Foam

Add

Adding

Radio 3

CheckboxFentanyl Citrate 800 mcg Oral Troches

Add

Adding

Radio 3

CheckboxFamotidine 20 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxFluorouracil 5%/Salicylic Acid 20% Topical Liquid

Add

Adding

Radio 3

CheckboxFinasteride 0.1%/Minoxidil 7% Topical Foam

Add

Adding

Radio 3

CheckboxFluoxetine 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxFluticasone Propionate 1%/Itraconazole 2% Topical Ointment

Add

Adding

Radio 3

CheckboxFluconazole 0.25% Nasal Spray

Add

Adding

Radio 3

CheckboxFentanyl 80 mg/0.1 mL Nasal Spray

Add

Adding

Radio 3

CheckboxFosinopril Sodium 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxFlurbiprofen 5%/Piroxicam 0.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxFluconazole 2%/Ibuprofen 2%/Ketoconazole 2%/Thymol 4% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxFluocinolone 0.05%/Ketoconazole 2%/Salicylic Acid 2% Topical Shampoo

Add

Adding

Radio 3

CheckboxFluconazole 2%/Salicylic Acid 6% Topical Shampoo

Add

Adding

Radio 3

CheckboxFludrocortisone Acetate 0.2 mg/5mL Oral Liquid

Add

Adding

Radio 3

CheckboxFurosemide 1 mg/ml Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxFluconazole 40 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxFamotidine 40 mg/10 mL Oral Liquid

Add

Adding

Radio 3

CheckboxFluvoxamine Maleate 50 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxEstradiol 0.125 mg/Estriol 0.5 mg/Testosterone 2 mg/ml Transdermal Cream

Add

Adding

Radio 3

CheckboxEstriol 0.3%/Progesterone 2%/Retinoic Acid 1% Topical Cream

Add

Adding

Radio 3

CheckboxEstriol 2 mg/Progesterone 50 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2 mg/Progesterone 50 mg/Testosterone 2 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.625 mg/Estriol 0.625 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.25 mg/Progesterone 100 mg Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.05 mg/ml Vaginal Cream

Add

Adding

Radio 3

CheckboxEnalapril Maleate 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxEstriol 0.625 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg Slow Release (MEM4) Oral Capsules

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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