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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

CheckboxDehydroepiandrosterone 5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDisulfiram 500 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 15% Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 4 mg/Diphenhydramine HCl 25 mg/Metoclopramide HCl 11.8 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 5% Topical Gel

Add

Adding

Radio 3

CheckboxDoxycycline 100 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxDiazepam 10 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxDoxycycline 1% Topical Gel

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 25 mg/Promethazine HCl 25 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5%/Testosterone 13.33% Topical Cream

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 50 mg Oral Troche

Add

Adding

Radio 3

CheckboxDiltiazem HCl 5 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDoxepin 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDimercaptosuccinic Acid 100 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxDexamethasone 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 50 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDiazepam 0.2% Otic Solution

Add

Adding

Radio 3

CheckboxDexamethasone 0.4%/Lidocaine HCL 2% Iontophoresis Liquid

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 15%/Lidocaine HCl 5%/Menthol 3% Topical Cream

Add

Adding

Radio 3

CheckboxDiltiazem HCl 2%/Lidocaine HCl 5% Rectal Ointment

Add

Adding

Radio 3

CheckboxDiltiazem HCl 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDoxycycline 40 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDexamethasone 0.1mg/Lidocaine 20 mg/ml Oral Rinse

Add

Adding

Radio 3

CheckboxDiphenhydramine HCL 12.5 mg/Nystatin 250K Units/Prednisone 2.5 mg/Tetracycline HCL 125 mg/15 mL Oral Mouthwash

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 150 mg/Testosterone 20 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxDoxepin HCl 10%/Ketamine HCl 10%/Ketoprofen 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 2.5%/Ketoprofen 20%/Lidocaine HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg/Estradiol 0.2 mg/Estriol 0.8 mg/Progesterone 20 mg/Testosterone 1 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxDiphenhydramine HCL 12.5/Hydrocortisone 2.5 /Nystatin 62500 Units/Tetracycline HCL 62.5/10 mL Oral Mouthwash

Add

Adding

Radio 3

CheckboxDiphenhydramine 12.5 mg/Haloperidol 0.5 mg/Lorazepam 0.5 mg/Metoclopramide 5mg Transdermal Gel

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 12.5 mg/Haloperidol 1 mg/Lorazepam 1 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxDimethyl Sulfoxide 5%/Gabapentin 5%/Ketoprofen 5%/Tetracaine 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxDoxycycline 50 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxDiazoxide 100 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDoxycycline Hyclate 5.75 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 7 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 4%/Lidocaine HCl 4%/Orphenadrine Citrate 5% Topical Gel

Add

Adding

Radio 3

CheckboxDiltiazem HCl 0.2% Rectal Ointment

Add

Adding

Radio 3

CheckboxDextromethorphan Hydrobromide 30 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDimercaptosuccinic Acid 70 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Ketamine HCl 2.3% Transdermal Gel

Add

Adding

Radio 3

CheckboxDiazepam 5 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDoxylamine succinate 10 mg/Pyridoxine HCl 10 mg Oral Troches

Add

Adding

Radio 3

CheckboxDoxepin HCl 0.565% Oral Mouthwash

Add

Adding

Radio 3

CheckboxDexamethasone 0.8 mg/ml/Dipenhydramine HCl 2.5 mg/ml Mouthwash

Add

Adding

Radio 3

CheckboxDanazol 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 50 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDimethyl Sulfoxide 10%/Ketoprofen 10%/Lidocaine 10% Topical Gel

Add

Adding

Radio 3

CheckboxDoxylamine Succinate 10 mg/Ginger 600 mg/Pyridoxine HCl 40 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxDesmopressin Acetate 0.2 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxDexamethasone Phosphate 24 mg/ml Otic Liquid

Add

Adding

Radio 3

CheckboxDiphenhydramine 25 mg p mL/Haloperidol 1 mg p mL/Lorazepam 1 mg p mL Transdermal Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDoxycycline 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxDiphenhydramine HCL 12.5 mg/Haloperidol 0.5 mg/Lorazepam 0.5 mg/Metoclopramide 5 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 60 mg Oral Troches

Add

Adding

Radio 3

CheckboxDoxycycline Hyclate 17.25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 35 mg/Pregnenolone 25 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone (DHEA) 100 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxDiltiazem HCl 27 mg/Lidocaine 67.5 mg/Pramoxine HCl 27 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 0.11% Topical Cream

Add

Adding

Radio 3

CheckboxDexamethasone 4 mg/Diphenhydramine HCL 20 mg/Metoclopramide HCL 4.72 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxDexamethasone Acetate 0.055%/Progesterone 1% Topical Foam

Add

Adding

Radio 3

CheckboxDiazoxide 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDoxycycline Hyclate 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDesonide 0.05%/Niacinamide 2% Topical Lotion

Add

Adding

Radio 3

CheckboxDiazoxide 300 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDimercaptosuccinic Acid 300 mg/Lipoic Acid 300 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 6%/Gabapentin 6% Transdermal Gel

Add

Adding

Radio 3

CheckboxDexamethasone Phosphate 10 mg/ml Otic Liquid

Add

Adding

Radio 3

CheckboxDiphenhydramine 12.5 mg/Lorazepam 0.5 mg/Metoclopramide 10 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDexamethasone 4 mg/Diphenhydramine HCl 20 mg/Metoclopramide HCl 4 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxDoxepin HCl 10%/Ketamine HCl 2%/Pentoxifylline 10%/Tetracaine 8% Transdermal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDiphenhydramine 12.5 mg/Haloperidol 0.5 mg/Lorazepam 0.5 mg/Metoclopramide 11.82 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 20 mg/g Transdermal Cream

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 5%/Indomethacin 5%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 50 mg/Haloperidol 1 mg/Lorazepam 1 mg/Metoclopramide HCl 11.82 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDexamethasone 10 mg/ml/Diphenhydramine HCL 25 mg/ml/Lorazepam 1 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 5 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxDiphenhydramine HCL 25 mg/Haloperidol 1 mg/Lorazepam 1 mg/Metoclopramide HCl 11.82 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxDiclazuril 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDipyridamole 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDiphenhydramine HCL 25 mg/Haloperidol 0.5 mg/Metoclopramide 10 mg/g Transdermal Gel

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 25 mg/Haloperidol 1 mg/Lorazepam 1 mg/Metoclopramide 10 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 12.5 mg/Lorazepam 1 mg/Metoclopramide 20 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxDimethyl Sulfoxide 5%/Gabapentin 5%/Ketoprofen 10%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 0.1%/Diclofenac Sodium 10%/Gabapentin 1.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxDexamethasone 2%/Ketoprofen 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxDoxycycline 0.025% Otic Liquid

Add

Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 6.6 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxDexamethasone 1 mg/Diphenhydramine HCl 50 mg/Lorazepam 1 mg/Metoclopramide HCl 11.82 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 3%/Diclofenac Na 4%/Guaifenesin 10% Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone Phosphate 0.1%/Tobramycin 0.3% Nasal Spray

Add

Adding

Radio 3

CheckboxDoxepin HCl 5.65%/Naloxone HCl 1% Topical Cream

Directions:

QTY:

Refills

1

2

3

4

5

6

7

8

9

10

xPrescriber's Signature:

Date

3

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Fill out the Pharmacy Name and Fax Number, then fax it to the Pharmacy.

Pharmacy Name

Pharmacy Fax Number

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Thank you! Your submission has been received!

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