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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
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
Prescriber and Prescription Information
Prescriber's First Name
Prescriber's Last Name
Phone Number
Fax Number
Address
City
State
ZIP
NPI/DEA
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Adding
Radio 3
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Doxylamine Succinate 10 mg/Pyridoxine HCl 10 mg Slow Release (MEM4) Oral Capsules
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Estradiol 0.2 mg/Estriol 0.8 mg/0.25 mL Sublingual Drops
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Estradiol 0.9 mg/Estriol 3.6 mg/ml Topical Cream
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Estradiol 0.1 mg/Progesterone 20 mg/Testosterone 2 mg/g Topical Cream
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Epinephrine HCl 0.1%/Lidocaine HCl 6%/Tetracaine HCl 4% Topical Gel
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Estradiol 0.1 mg Oral Troches
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Estradiol 0.5mg Slow Release (MEM4) Oral Capsules
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Ergoloid Mesylates 1 mg Oral Capsules
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Estradiol 0.5 mg/ml Estriol 0.5 mg/ml/Testosterone 20 mg/ml Vaginal Gel
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Estradiol 0.2 mg/Estriol 0.8 mg/Progesterone 25 mg/Testosterone 0.25 mg/ml Topical Cream
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Estradiol 0.25 mg/Estriol 1.0 mg Vaginal Suppository
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Estradiol 1 mg/Estriol 5 mg Oral Capsules
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Dutasteride 1 mg/ml Sublingual Liquid
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Epinephrine 0.05%/Lidocaine HCl 4%/Tetracaine HCl 2% Topical Liquid
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Epinephrine 0.05%/Lidocaine HCl 4%/Tetracaine 2% Topical Gel
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Estradiol 0.05 mg/Estriol 0.05 mg/Progesterone 25 mg/Testosterone 1.8 mg Slow Release (MEM4) Oral Capsules
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Estradiol 0.625 mg/Estriol 0.625 mg Oral Capsules
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Edetate Disodium 17% Oral Rinse
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Erythromycin 0.5%/Hydrocortisone Acetate 1% Topical Ointment
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Estradiol 0.125 mg/Estriol 0.5 mg Oral Capsules
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Estriol 8mg/ml Topical Cream
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Estradiol 0.25 mg/Estriol 0.25 mg/Progesterone 20 mg/gm Topical Cream
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Estradiol 1 mg/ml Topical Cream
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Econazole Nitrate 1%/Terbinafine HCL 2.5% Nail Liquid
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Estradiol 0.05%/Estriol 0.2%/Progesterone 3.5%/Testosterone 1% Topical Cream
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Estriol 3 mg/ml Vaginal Cream
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Estradiol 0.5 mg/Estriol 2 mg/ml/Progesterone 150 mg/ml Topical Cream
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Dutasteride 0.2%/Minoxidil 8%/Tretinoin 0.01% Topical Foam
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Erythromycin 0.025%/Lidocaine HCl 2%/Triamcinolone Acetonide 0.1% Oral Rinse
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Edetate Disodium 0.1%/Gentamicin 0.3%/Mupirocin 0.2% Nasal Spray
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Estradiol 0.25 mg/Progesterone 25 mg Oral Troche
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Estriol 0.3%/Glycolic Acid 5% Topical Cream
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Estriol 1.25 mg/Pregnenolone 10 mg/Progesterone 50 mg/Testosterone 1 mg Oral Capsules
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Estradiol 0.6 mg/Estriol 2.4 mg Slow Release (MEM4) Oral Capsules
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Estradiol 1 mg/ml/Estriol 4 mg/ml Topical Cream
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Enrofloxacin 18 mg Oral Capsules
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Estradiol 2.8 mg/Estriol 1.2 mg/Testosterone 2.5 mg Oral Troches
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Estradiol 0.125 mg/Estriol 0.125 mg/ml Topical Cream
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Estradiol 2 mg/Progesterone 100 mg Slow Release (MEM4) Oral Capsules
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Dutasteride 1%/Minoxidil 10% Topical Liquid
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Estradiol 0.1 mg/Estriol 0.4 mg/Progesterone 175 mg/Testosterone 2 mg Oral Troche
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Estradiol 0.75 mg/Estriol 2.5 mg/Estrone 0.25 mg/g Topical Gel
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Estradiol 0.5 mg/Progesterone 100 mg Oral Capsules
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Estriol 3 mg Vaginal Suppository
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Dyclonine HCl 1% Oral Rinse
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Estradiol 0.5 mg/Estriol 2.0 mg/Progesterone 100 mg/Testosterone 0.5 mg Oral Capsules
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Estradiol 0.4 mg/Estriol 1.6 mg Oral Capsule
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Epinephrine 0.02%/Lidocaine HCl 2%/Tetracaine 2% Topical Gel
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Escitalopram 1 mg/ml Oral Liquid (Gluten Free)
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Estradiol 1 mg/Progesterone 100 mg Slow Release (MEM4) Oral Capsules
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Estriol 0.3%/Progesterone 2%/Retinoic Acid 0.1% Topical Cream
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Estriol 1.0 mg Vaginal Suppository
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Estradiol 1 mg/Progesterone 100 mg Oral Sublingual Troches
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Enrofloxacin 50 mg/ml Oral Liquid
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Estradiol 0.4 mg/Estriol 1.6 mg/Testosterone 2 mg/ml Topical Cream
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Radio 3
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Estradiol 0.5 mg/Progesterone 20 mg/ml Topical Cream
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Estradiol 0.5 mg/Estriol 2 mg Slow Release (MEM4) Oral Capsules
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Epinephrine 0.18%/Lidocaine HCl 4%/Tetracaine 0.5% Topical Gel
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Dutasteride 0.25%/Finasteride 0.25% Topical Liquid
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Edetate Disodium 500 mg Rectal Suppository
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Estriol 1 mg/Estradiol 0.25 mg Oral Troches
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Estradiol 0.5 mg/Estriol 2 mg Oral Capsules
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Estradiol 0.5 mg/Progesterone 100 mg/Testosterone 1 mg Oral Capsules
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Estradiol 0.6 mg/Estriol 2.4 mg/Progesterone 100 mg/Testosterone 2.5 mg Oral Capsules
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Estradiol 0.5 mg/Estriol 0.5 mg/ml Topical Cream
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Estradiol 0.2 mg/Estriol 0.8 mg/Testosterone 2 mg/g Transdermal Cream
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Edetate Disodium 600 mg Oral Capsules
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Radio 3
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Enrofloxacin 100 mg/ml Oral Liquid
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Radio 3
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Estradiol 0.01%/Glycolic Acid 15% Topical Gel
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Radio 3
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Edetate Disodium 1% Nasal Liquid
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Estriol 1.6 mg/Estradiol 0.4 mg Oral Sublingual Troches
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Estradiol 0.1 mg Vaginal Suppository
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Estradiol 0.5 mg/Estriol 2 mg p mL/Progesterone 100 mg/ml Topical Cream
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Radio 3
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Estriol 1.0 mg/Estradiol 0.25 mg Oral Sublingual Troches
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Adding
Radio 3
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Estradiol 0.4 mg/ml/Estriol 0.6 mg/ml/Progesterone 30 mg/ml/Testosterone 0.25 mg/ml Topical Cream
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Adding
Radio 3
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Estradiol 0.3 mg/g/Estriol 1.2 mg/g Topical Cream
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Radio 3
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Estriol 0.1 mg/0.5 mL Oral Sublingual Drops
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Estriol 2 mg Oral Troche
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Radio 3
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Estradiol 0.5 mg/Estriol 2 mg/Progesterone 50 mg/Testosterone 3.5 mg Slow Release (MEM4) Oral Capsules
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Adding
Radio 3
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Dutasteride 0.1%/Minoxidil 5% Topical Shampoo
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Radio 3
Checkbox
Estradiol 0.3 mg/Estriol 1.2 mg/Progesterone 100 mg/Testosterone 2 mg Slow Release (MEM4) Oral Capsules
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Adding
Radio 3
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Enrofloxacin 0.5%/Ketoconazole 1%/Triamcinolone Acetonide 0.1% Otic Ointment
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Radio 3
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Erythromycin 2%/Hydrocortisone 0.25%/Metronidazole 2%/Miconazole 2%/Sulfacetamide 5% Topical Cream
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Enalapril Maleate 2 mg/ml Oral Liquid
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Estradiol 0.7 mg/Estriol 2.8 mg/ml Topical Cream
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Radio 3
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Estriol 1.2 mg/Estradiol 0.3 mg Oral Sublingual Troches
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Radio 3
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Estradiol 0.05 mg/ml/Estriol 0.05 mg/ml Topical Cream
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Adding
Radio 3
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Escitalopram 7.5 mg Oral Capsules
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Estradiol 0.25 mg/Estriol 1.0 mg Slow Release (MEM4) Oral Capsules
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Radio 3
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Estradiol 0.3 mg/Estriol 1.2 mg/Testosterone 2 mg/gm Transdermal Cream
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Estradiol 0.8 mg/Estriol 3.2 mg/Testosterone 3 mg/ml Topical Cream
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Estradiol 2 mg Vaginal Suppository
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Enrofloxacin 20 mg/ml Oral Liquid
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Estradiol 0.3 mg/Estriol 1.2 mg Oral Capsules
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Diclofenac Sodium 10%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel
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Dehydroepiandrosterone DHEA 50 mg/0.2 mL Transdermal Gel
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Dibutyl Squarate 0.1% Topical Liquid
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Diclofenac Sodium 8% Topical Gel
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Diphenhydramine 12.5 mg/Haloperidol 0.5 mg/Lorazepam 0.5 mg Rectal Suppository
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Dapsone 5%/Pyridoxine HCl 1% Topical Gel
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Directions:
QTY:
Refills
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Prescriber's Signature:
Date
3
Fill out the Pharmacy Name and Fax Number, then fax it to the Pharmacy.
Pharmacy Name
Pharmacy Fax Number
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