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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

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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

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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

CheckboxEstradiol 0.125 mg/Estriol 0.5 mg/ml Topical Cream

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Adding

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CheckboxEstradiol 0.4 mg/g/Estriol 1.6 mg/g Topical Cream

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Adding

Radio 3

CheckboxDutasteride 0.5 mg/ml Topical Liquid

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Adding

Radio 3

CheckboxEstradiol 0.5 mg/g/Estriol 2 mg/g/Testosterone 0.3 mg/gm Topical Cream

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Adding

Radio 3

CheckboxEstradiol 0.75 mg/Estriol 1.75 mg/ml Vaginal Cream

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Adding

Radio 3

CheckboxEstradiol 0.4 mg/Estriol 1.6 mg/Progesterone 50 mg/Testosterone 5 mg/ml Sublingual Drops

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Adding

Radio 3

CheckboxEstradiol 0.05 mg/Estriol 0.2 mg/Progesterone 30 mg/gm Topical Cream

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Adding

Radio 3

CheckboxEstradiol 1 mg/Estriol 4 mg/Testosterone 2 mg Slow Release (MEM4) Oral Capsules

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Adding

Radio 3

CheckboxEstradiol 0.25 mg/Estriol 1 mg/Testosterone 2 mg/gm Transdermal Cream

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Adding

Radio 3

CheckboxEstradiol 0.01%/Hyaluronic Acid 0.2% Vaginal Cream

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Adding

Radio 3

CheckboxEstradiol 0.065 mg/Estriol 0.26 mg Slow Release (MEM4) Oral Capsules

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Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2 mg/Progesterone 100 mg/Testosterone 2 mg Slow Release (MEM4) Oral Capsules

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Adding

Radio 3

CheckboxEstradiol 1 mg/Progesterone 175 mg/Testosterone 1.25 mg Oral Troche

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Adding

Radio 3

CheckboxEstradiol 0.01%/Testosterone 0.1% Vaginal Cream

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Adding

Radio 3

CheckboxEstradiol 0.16 mg/Estriol 0.64 mg/Progesterone 12.5 mg Oral Capsules

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Adding

Radio 3

CheckboxEstradiol 0.16 mg/Estriol 0.64 mg/Progesterone 40 mg/ml Topical Cream

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Adding

Radio 3

CheckboxErythromycin 2%/Hydrocortisone 1%/Terbinafine HCl 1% Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.1 mg p mL/Estriol 0.8 mg p mL/Progesterone 40 mg p mL/Testosterone 1 mg p mL Topical Cream

Add

Adding

Radio 3

CheckboxErythromycin 4.0%/Zinc Sulfate 1.2% Topical Lotion

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Adding

Radio 3

CheckboxEstradiol 0.125 mg/Estriol 0.5 mg/Progesterone 2.5 mg Oral Capsules

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Adding

Radio 3

CheckboxDried Aluminum Hydroxide Gel 1503.27 mg Oral Capsules

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Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2 mg/Progesterone 40 mg/ml Topical Cream

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Adding

Radio 3

CheckboxEstriol 1 mg Vaginal Capsules

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Adding

Radio 3

CheckboxEstradiol 0.45 mg/Estriol 1.8 mg Oral Capsules

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Adding

Radio 3

CheckboxEnrofloxacin 50 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxEstradiol 0.6 mg/Estriol 2.4 mg/Progesterone 50 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2.0 mg/Testosterone 2 mg/g Transdermal Cream

Add

Adding

Radio 3

CheckboxEstradiol 1.25 mg/Progesterone 200 mg Oral Troche

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Adding

Radio 3

CheckboxEstradiol 0.25 mg/Estriol 1 mg Oral Troche

Add

Adding

Radio 3

CheckboxEstradiol 1 mg/Estriol 4 mg/Progesterone 100 mg/Testosterone 4 mg/ml Transdermal Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2mg/Progesterone 100 mg/Testosterone 2 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxEstriol 1 mg/ml Vaginal Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.4 mg/Estriol 1.6 mg/Progesterone 50 mg/Testosterone 3 mg Slow Release (MEM4) Oral Capsules

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Adding

Radio 3

CheckboxEsomeprazole 10 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxEstradiol 0.2 mg/ml/Progesterone 20 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxEstriol 1 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.45 mg/Estriol 1.8 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2 mg/gm Topical Cream

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Adding

Radio 3

CheckboxEnalapril Maleate 5 mg/ml/Spironolactone 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxEstradiol 0.125 mg/Estriol 0.5 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxErythromycin 4% Topical Lotion

Add

Adding

Radio 3

CheckboxEstradiol 0.25 mg/Estriol 1.0 mg/Progesterone 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 1.2 mg/Estriol 4.8 mg/Testosterone 4 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.2 mg/Estriol 0.8 mg Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2 mg/Progesterone 20 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.2 mg/ml/Estriol 0.8 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 1 mg/Estriol 4 mg/Progesterone 40 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.45 mg/Estriol 1.8 mg/Progesterone 50 mg/Testosterone 2 mg Oral Tablets

Add

Adding

Radio 3

CheckboxEstradiol 0.2 mg/Estriol 0.8 mg Slow Release (MEM4) Oral Capsules

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Adding

Radio 3

CheckboxEstradiol 0.06 mg/Estriol 0.24 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 1.5 mg/Estriol 0.6 mg/Progesterone 25 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.6 mg/Estriol 2.4 mg/Testosterone 2 mg/gm Transdermal Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.01% Vaginal Cream (Propylene Glycol Free)

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2.0 mg Vaginal Suppository

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Adding

Radio 3

CheckboxErythromycin 4%/Tretinoin 0.01% Topical Gel

Add

Adding

Radio 3

CheckboxEstradiol 0.2 mg/Estriol 0.8 mg/Progesterone 20 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxEstriol 0.5% Vaginal Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.4 mg/Estriol 1.6 mg/Testosterone 2 mg/g Transdermal Cream

Add

Adding

Radio 3

CheckboxErythromycin 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2.0 mg/Progesterone 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxEstriol 0.3%/Hyaluronic Acid 0.1% Topical Cream

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Adding

Radio 3

CheckboxEstradiol 0.4 mg/Estriol 1.6 mg/Progesterone 300 mg/Testosterone 1 mg Oral Troches

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Adding

Radio 3

CheckboxEstradiol 0.01% to 10% Topical Cream

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Adding

Radio 3

CheckboxEstriol 0.03%/Glycolic Acid 10% Topical Cream

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Adding

Radio 3

CheckboxEconazole Nitrate 1%/Ibuprofen 2%/Urea 40% Topical Ointment

Add

Adding

Radio 3

CheckboxEdetate Calcium Disodium 750 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxEnrofloxacin 22.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAluminum Hydroxide Gel 8.37% Oral Liquid

Add

Adding

Radio 3

CheckboxEstriol 1 mg/ml/Testosterone 0.25 mg/ml Vaginal Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.25 mg/Estriol 1 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 2 mg/Estriol 1 mg Oral Capsules

Add

Adding

Radio 3

CheckboxEdetate Disodium 0.1%/Gentamicin 0.25%/Itraconazole 0.2%/Mupirocin 0.2% Nasal Spray

Add

Adding

Radio 3

CheckboxErythromycin 2%/Hydrocortisone 0.5% Scalp Lotion

Add

Adding

Radio 3

CheckboxDutasteride 0.125 mg Oral Capsules

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Adding

Radio 3

CheckboxEstradiol 0.06 mg/Estriol 0.24 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.4 mg/Estriol 1.6 mg/Progesterone 50 mg/Testosterone 1 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxEstradiol 0.025 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxEnalapril Maleate 5 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxEstriol 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.25 mg/Estriol 1 mg/Progesterone 150 mg/Testosterone 0.5 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 0.625 mg/ml Vaginal Cream

Add

Adding

Radio 3

CheckboxEstriol 2.4 mg/Estradiol 0.6 mg/Progesterone 25 mg Oral Sublingual Troches

Add

Adding

Radio 3

CheckboxEnalapril Maleate 2.5 mg/0.1 mL Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxEdetate Na 1%/Gentamicin 0.5%/Mupirocin 0.2% Nasal Spray

Add

Adding

Radio 3

CheckboxEstradiol 0.6 mg/Estriol 2.4 mg/Testosterone 2 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 1 mg/Estriol 4 mg/Progesterone 75 mg/Testosterone 6 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxEstradiol 2 mg/Progesterone 100 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxEdetate Disodium 1%/Gentamicin 0.025%/Itraconazole 0.2%/Mupirocin 0.2% Topical Ointment

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 0.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 0.5 mg/Testosterone 2 mg/gm Topical Cream

Add

Adding

Radio 3

CheckboxEnrofloxacin 50 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxEstradiol 0.25 mg/ Estriol 0.25 mg/ Progesterone 50 mg Oral Troche

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Adding

Radio 3

CheckboxEstradiol 0.1%/Triamcinolone Acetonide 0.1% Vaginal Cream

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Adding

Radio 3

CheckboxErythromycin 250 mg Oral Capsules (Gluten Free)

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Adding

Radio 3

CheckboxDyclonine Hydrochlorine 1% Oral Dental Gel

Add

Adding

Radio 3

CheckboxEdetate Disodium 30 mg/ml Catheter Irrigation Liquid

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 1 mg Topical Cream

Add

Adding

Radio 3

CheckboxEstriol 1.0 mg/Estradiol 0.25 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/Estriol 2 mg/Progesterone 100 mg/Testosterone 2 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxDutasteride 0.5% 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

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