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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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Visit the Tutorials tab to learn more.

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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

CheckboxDiclofenac Sodium 4%/Lidocaine 2% Topical Gel

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Adding

Radio 3

CheckboxDexamethasone 4 mg Rectal Suppository

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Adding

Radio 3

CheckboxDehydroepiandrosterone 20 mg/Oxytocin 60 IU/Testosterone 6 mg/gram Topical Cream

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Adding

Radio 3

CheckboxDantrolene Sodium 50 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxDehydroepiandrosterone 15 mg Slow Release (MEM4) Oral Capsules

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Adding

Radio 3

CheckboxDiazepam 15 mg Slow Release (MEM4) Oral Capsules

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Adding

Radio 3

CheckboxDexamethasone 4 mg/ml Transdermal Gel

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Adding

Radio 3

CheckboxDehydroepiandrosterone 8 mg/ml Topical Cream

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Adding

Radio 3

CheckboxDicloxacillin 62.5 mg/5 mL Oral Liquid

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Adding

Radio 3

CheckboxDehydroepiandrosterone 37.5 mg Oral Capsules

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Adding

Radio 3

CheckboxDexamethasone 0.1 mg/ml/Tacrolimus 0.1 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxDiazepam 10 mg Rectal Suppository

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Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Lidocaine HCl 2%/Menthol 2% Transdermal Gel

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Adding

Radio 3

CheckboxDiltiazem HCl 2%/Hydrocortisone 3%/Lidocaine HCl 5% Topical OIntment

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Adding

Radio 3

CheckboxDiclofenac Sodium 6%/Dimethyl Sulfoxide 5%/Indomethacin 6%/Lidocaine 6 % Transdermal Gel

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Adding

Radio 3

CheckboxDiclofenac Sodium 50 mg/Misoprostol 200 mcg Rectal Suppository

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Adding

Radio 3

CheckboxDexamethasone Phosphate 0.1% Nasal Spray

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Adding

Radio 3

CheckboxDexamethasone 1 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxDiclofenac Sodium 4%/Menthol 3% Topical Gel

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Adding

Radio 3

CheckboxDexamethasone 0.1%/Hydroquinone 4%/Tretinoin 0.1% Topical Cream

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Adding

Radio 3

CheckboxDiltiazem HCl 2% Rectal Ointment

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Adding

Radio 3

CheckboxDexamethasone 0.1%/Ketoconazole 2% Otic Liquid

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Adding

Radio 3

CheckboxDiazepam 5 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxDiltiazem HCl 10 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 20 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDiltiazem HCl 2 % Rectal Ointment

Add

Adding

Radio 3

CheckboxDimethyl Sulfone 10% Topical Cream

Add

Adding

Radio 3

CheckboxDiltiazem 2% Rectal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10 mg/Estradiol 0.75 mg/Estriol 3 mg/Progesterone 75 mg Oral Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg/Progesterone 100 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxDexamethasone 2 mg Rectal Suppository

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Adding

Radio 3

CheckboxDimercaptosuccinic Acid 150 mg/0.5 mL Transdermal Gel

Add

Adding

Radio 3

CheckboxDexamethasone 6 mg Rectal Suppository

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxDiltiazem HCl 10 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxDehydroepiandrosterone 15 mg Oral Capsules

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Adding

Radio 3

CheckboxClomipramine HCl 2.5 mg/5 mg Oral Capsules (Vet)

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Adding

Radio 3

CheckboxCyclosporin A 0.5% Oral Rinse

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Adding

Radio 3

CheckboxCoal Tar Solution 5%/Fluocinonide 0.025%/Salicylic Acid 3% Topical Ointment

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Adding

Radio 3

CheckboxCyanocobalamin 0.07% Topical Lotion

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Adding

Radio 3

CheckboxClindamycin Phosphate 2.38% Vaginal Gel

Add

Adding

Radio 3

CheckboxClindamycin Phosphate 1.19% Topical Gel

Add

Adding

Radio 3

CheckboxCollagenase 250 IU/g/Misoprostol 0.0024%/Phenytoin 5% Topical Cream

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05%/Minoxidil 5% Topical Foam

Add

Adding

Radio 3

CheckboxClonidine HCl 0.232%/Gabapentin 8%/Ketamine HCl 5.75%/Lidocaine HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Gabapentin 6%/Lidocaine 10% Topical Gel

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.0025%/Ibuprofen 6%/Indomethacin 6%/Lidocaine 4% Topical Ointment

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05%/Salicylic Acid 25% Topical Cream

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Gabapentin 6%/Ketamine HCl 11.5%/Lidocaine HCl 3.5% Topical Gel

Add

Adding

Radio 3

CheckboxCoenzyme Q10 700 mg/15 mL Oral Liquid

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Adding

Radio 3

CheckboxClonidine 0.2% Topical Cream

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Adding

Radio 3

CheckboxClotrimazole 500 mg Vaginal Suppository

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Adding

Radio 3

CheckboxCiprofloxacin 250 mg/5 mL Gastric Tube Liquid

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Adding

Radio 3

CheckboxClindamycin 1% Topical Shampoo

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Adding

Radio 3

CheckboxClobazam 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Gabapentin 4%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Gabapentin 4%/Ketoprofen 10%/Lidocaine HCl 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.23%/Diclofenac Sodium 10%/Ketamine HCl 5.75% Topical Gel

Add

Adding

Radio 3

CheckboxCromolyn Sodium 2% Topical Ointment

Add

Adding

Radio 3

CheckboxClarithromycin 250 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxClotrimazole 0.33%/Hydrocortisone 0.33%/Zinc Oxide 3.3% Topical Cream

Add

Adding

Radio 3

CheckboxClonazepam 0.1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1%/Ketoprofen 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 1.2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClomiphene Citrate 25 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 10 mg/Lidocaine HCl 10 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxClonidine HCl 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Gabapentin 6%/Ketamine HCl 11.5%/Nifedipine 3%/Pentoxifylline 3% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.166%/Diclofenac Sodium 2%/Gabapentin 6%/Lidocaine 2%/Pentoxifylline 5% Topical Gel

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05%/Zinc Sulfate 2.5% Topical Cream

Add

Adding

Radio 3

CheckboxClonidine HCl 0.1 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Hydrocortisone 1%/Sucralfate 15%/Tetracaine 0.05% Oral Rinse

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.0125%/Coal Tar 5%/Mometasone Furoate 0.12%/Salicylic Acid 5% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Solution 8%/Salicylic Acid 4% Topical Lotion

Add

Adding

Radio 3

CheckboxCyanocobalamin 1 mg/Folic Acid 2.5 mg/Pyridoxine HCl 25 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCurcumin 2% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCL 0.2%/Gabapentin 10%/Ketamine HCL 15%/Nifedipine 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Gabapentin 6% Transdermal Gel

Add

Adding

Radio 3

CheckboxClindamycin 2%/Tretinoin 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.07% Topical Cream

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Flurbiprofen 5%/Gabapentin 5% Topical Gel

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.5 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxClopidogrel 37.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 3%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxCromolyn Sodium 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.07%/Hydrocortisone 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1%/Ibuprofen 1%/Ketoprofen 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCL 1%/Diclofenac Sodium 8%/Lidocaine HCL 10% Topical Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine 5%/Ketoprofen 10%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxCoal Tar Solution 10%/Salicylic Acid 10% Topical Ointment

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Gabapentin 6%/Ketamine HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxCromolyn Sodium 10% Topical Ointment

Add

Adding

Radio 3

CheckboxCyproheptadine HCl 20 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Hydrocortisone 2% Topical Cream

Add

Adding

Radio 3

CheckboxClindamycin HCl 1%/Hydrocortisone 1%/Sulfacetamide Sodium 5% Topical Lotion

Add

Adding

Radio 3

CheckboxCyanocobalamin 1000 mcg/mL Oral Sublingual Drops

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Ketamine HCl 10%/Pentoxifylline 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxCoenzyme Q10 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

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