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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

Radio 3

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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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

You may need to scale up or down your order form when printing to make it fit the page.

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