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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

CheckboxDexamethasone Sodium Phosphate 5.28 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone DHEA 25 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxDiazepam 10 mg/g Vaginal Cream

Add

Adding

Radio 3

CheckboxDonepezil HCL 5 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 3%/Lidocaine 5% Topical Cream

Add

Adding

Radio 3

CheckboxDimercaptosuccinic Acid 384 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDimercaptosuccinic Acid 70 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 6%/Flurbiprofen 6%/Gabapentin 6% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 7.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxDoxazosin 4 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxDoxycycline 250 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg/0.1 mL Topical Cream

Add

Adding

Radio 3

CheckboxDapsone 6% Topical Gel

Add

Adding

Radio 3

CheckboxDimethyl Sulfone 20% Oral Spray

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10%/Testosterone 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxDimethyl Sulfoxide 10% Topical Gel

Add

Adding

Radio 3

CheckboxDHEA 2.5%/Estradiol 0.02%/Estriol 0.08%/Progesterone 3%/Testosterone 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxDimethyl Sulfoxide 50%/Fluconazole 2%/Ketoconazole 2%/Terbinafine HCl 2% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 5%/DMSO 30%/Menthol 4% Topical Gel

Add

Adding

Radio 3

CheckboxDesonide 0.05%/Hydroquinone 6% Topical Cream

Add

Adding

Radio 3

CheckboxDHEA 5 mg/Estradiol 0.35 mg/Estriol 2 mg/Progesterone 30 mg/Testosterone 0.15 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 20 mg/Melatonin 3 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxDexamethasone 0.4% Oral Rinse

Add

Adding

Radio 3

CheckboxDibutyl Squarate 0.1%-5% Topical Liquid

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Lidocaine HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 15 mg/Pregnenolone 30 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 3%/Dimethyl Sulfoxide 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 1.25 mg/0.5 mL Topical Cream

Add

Adding

Radio 3

CheckboxDiazepam 0.5% Rectal Gel

Add

Adding

Radio 3

CheckboxDexamethasone 0.11%/Gentamicin 0.3% Nasal Spray

Add

Adding

Radio 3

CheckboxDexamethasone 4 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDapsone 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDexamethasone 0.15%/Sucralfate 7.5% Oral Rinse

Add

Adding

Radio 3

CheckboxDHEA 3.25 mg/Estriol 2 mg/Vitamin E Acetate 200 IU Vaginal Suppository

Add

Adding

Radio 3

CheckboxDexamethasone 0.4%/Ketoprofen 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 4%/Gabapentin 5%/Lidocaine HCl 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 0.11%/Sulfacetamide 10% Topical Liquid

Add

Adding

Radio 3

CheckboxDexamethasone 2 mg/Ketamine HCl 46 mg/Lidocaine 10 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10 mg/Estradiol 0.65 mg/Estriol 2.75 mg/Progesterone 15 mg/Testosterone 1 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxDiltiazem HCl 130 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDHEA 0.5% Vaginal Cream

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 6%/DMSO 5%/Ibuprofen 6%/Lidocaine 2% Topical Ultrasound Gel

Add

Adding

Radio 3

CheckboxDimercaptosuccinic Acid 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 5%/Dimethyl Sulfoxide 15% Transdermal Gel

Add

Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 0.528% Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 4 mg/Haloperidol 1 mg/Lorazepam 0.5 mg/Metoclopramide 10 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxDiazepam 5 mg/g Vaginal Cream

Add

Adding

Radio 3

CheckboxDiazepam 20 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxDexamethasone 1 mg/Diphenhydramine 50 mg/Lorazepam 1 mg/Metoclopramide 10 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone Phosphate 0.5%/Itraconazole 0.2%/Mupirocin 0.2%/Xylitol 12% Nasal Liquid

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg/Estradiol 0.5 mg/Estriol 2 mg/Progesterone 30 mg/Testosterone 1 mg/g Transdermal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDexamethasone 0.15%/Ketoprofen 10%/Lidocaine 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxDexamethasone 4 mg/Diphenhydramine 20 mg/Metoclopramide 4.73 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDexamethasone 10 mg/Metoclopramide 10 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg/Testosterone 12.5 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 50 mg/Estradiol 0.5 mg/Estriol 0.5 mg/Pregnenolone 50 mg/Progesterone 100 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 3%/Fluconazole 3%/Itraconazole 3%/Terbinafine HCl 1% Topical Nail Liquid

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 200 mg Oral Troches

Add

Adding

Radio 3

CheckboxDiltiazem HCl 16 mg/ml/Phenytoin 10.87 mg/ml Topical Ointment

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 15 mg/g/Testosterone 3 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDexamethasone Phosphate 0.4% Iontophoresis Liquid

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 15 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 0.1%/Glycolic Acid 0.5%/Hydroquinone 5%/Tretinoin 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxDimethyl Sulfoxide 15%/Fluconazole 1%/Ibuprofen 2%/Tea Tree Oil 3% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 2%/Gabapentin 6% Topical Gel

Add

Adding

Radio 3

CheckboxDibutyl Squarate 0.5% Topical Ointment

Add

Adding

Radio 3

CheckboxDiazepam 5 mg/Ketamine HCl 57.5 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDexamethasone 0.1%/Minoxidil 5%/Tretinoin 0.025% Topical Foam

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 3%/Flurbiprofen 6%/Gabapentin 6% Topical Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10 mg/0.1 mL Oral Sublingual Drops

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone (DHEA) 2% Topical Cream

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxDexamethasone 8 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 0.44% Ultasound Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Dimethyl Sulfoxide 5% Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 20 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDiazepam 2.5 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 6% Transdermal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 1 mg/g/Estriol 0.25 mg/g Vaginal Cream

Add

Adding

Radio 3

CheckboxDiazepam 5 mg/2 mL Vaginal Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 3%/Lidocaine 2%/Menthol 4%/Prilocaine 2% Topical Cream

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10 mg/Estradiol 0.6 mg/Estriol 2.4 mg/Testosterone 1 mg/0.25 mL Topical Cream

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 5%/Gabapentin 4%/Ibuprofen 5%/Lidocaine HCL 4% Topical Gel

Add

Adding

Radio 3

CheckboxDanazol 200 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxDesmopressin 0.1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 50 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxDextromethorphan Hydrobromide 120 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxDibasic Sodium Phosphate 398 mg/Monobasic Sodium Phosphate 1102 mg/10 mL Oral Liquid

Add

Adding

Radio 3

CheckboxDiazoxide 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 3%/DMSO 10%/Gabapentin 6%/Lidocaine 5% Topical Cream

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10%/Progesterone 1% Topical Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10 mg/ml Sublingual Liquid

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 3%/Imiquimod 5%/Salicylic Acid 2% Topical Cream

Add

Adding

Radio 3

CheckboxDantrolene Sodium 25 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxDiltiazem HCl 2%/Lidocaine 1% Rectal Ointment

Add

Adding

Radio 3

CheckboxDexamethasone 0.1%/Hydroquinone 5%/Tretinoin 0.1% Topical Cream

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.

Thank you! Your submission has been received!

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