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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

Circle for steps.

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

Circle for steps.

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

CheckboxClobazam 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClobetasol-17-Propionate 0.05%/Zinc Pyrithione 0.25% Topical Spray

Add

Adding

Radio 3

CheckboxCiprofloxacin 1%/Ketoconazole 1% Otic Liquid

Add

Adding

Radio 3

CheckboxClomipramine HCl 25 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxClobetasol-17-Propionate 0.05%/Coal Tar Solution 5%/Salicyclic Acid 3% Topical Liquid

Add

Adding

Radio 3

CheckboxClobazam 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05%/Minoxidil 5%/Tretinoin 0.025% Topical Liquid

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05% Dental Gel

Add

Adding

Radio 3

CheckboxClindamycin 1.5%/Hydroquinone 3% Topical Gel

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.2% Topical Ointment

Add

Adding

Radio 3

CheckboxCitalopram 2.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Diclofenac Sodium 10%/Gabapentin 5% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.01 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCoal Tar 2% Topical Foam

Add

Adding

Radio 3

CheckboxCyclobenzaprine 0.5%/Ketoprofen 5% Topical Gel

Add

Adding

Radio 3

CheckboxClindamycin 1%/Glycolic Acid 4% Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar Solution 5%/Salicylic Acid 2% Topical Shampoo

Add

Adding

Radio 3

CheckboxClomipramine HCl 50 mg/Clonidine HCl 0.4 mg/Phenobarbital 120 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCyclophosphamide 30 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine 5%/Diclofenac Sodium 1%/Gabapentin 5%/Lidocaine 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCL 2%/Ibuprofen 10%/Ketoprofen 10%/Piroxicam 2%/Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine 5%/Diclofenac 1%/Gabapentin 5%/Lidocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxCromolyn Sodium 10%/Estradiol 0.01%/Lidocaine 10% Vaginal Cream

Add

Adding

Radio 3

CheckboxClindamycin 1%/Niacinamide 4%/Tretinoin 0.035% Topical Cream

Add

Adding

Radio 3

CheckboxClotrimazole 1%/Dimethyl Sulfoxide 35%/Ketoconazole 1%/Itraconazole 1% Tea Tree Oil 10%/Terbinafine HCL 1.7% Topical Nail Lacquer

Add

Adding

Radio 3

CheckboxCoenzyme Q10 4%/Methylcobalamin 0.07%/Mometasone Furoate 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Solution 3% Topical Cream

Add

Adding

Radio 3

CheckboxClotrimazole 100 mg Oral Troches

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Diclofenac Sodium 2%/Lidocaine HCl 2%/Tramadol HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar Solution 2%/Salicylic Acid 1% Topical Shampoo

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 0.5%/Ketoprofen 5%/Lidocaine HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxCoal Tar 2% Topical Lotion

Add

Adding

Radio 3

CheckboxCoenzyme Q10 1%/Lipoic Acid 5%/Vitamin E Acetate 5% Topical Cream

Add

Adding

Radio 3

CheckboxCiprofloxacin 250 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1%/Ketoprofen 10%/Lidocaine HCl 5.8% Transdermal Gel

Add

Adding

Radio 3

CheckboxCoenzyme Q10 150 mg/Riboflavin 400 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCoal Tar Solution 2% Salicylic Acid 5% Topical Shampoo

Add

Adding

Radio 3

CheckboxClonidine HCl 0.23%/Diclofenac Sodium 5%/Gabapentin 6%/Ketamine HCl 9.2%/Lidocaine 8%/Nifedipine 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxCoal Tar 2%/Hydrocortisone 0.4% Topical Ointment

Add

Adding

Radio 3

CheckboxCoal Tar Solution 10%/Salicylic Acid 2%/Sulfur 4%/Urea 20% Topical Ointment

Add

Adding

Radio 3

CheckboxClomipramine HCl 0.5% Oral Liquid

Add

Adding

Radio 3

CheckboxClonazepam 0.5 mg/ml Oral Rinse

Add

Adding

Radio 3

CheckboxClonazepam 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClioquinol 1%/Fluocinolone Acetonide 0.1% Otic Liquid

Add

Adding

Radio 3

CheckboxCromolyn Sodium 0.22% Topical Cream

Add

Adding

Radio 3

CheckboxClonidine HCl 430 µg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxCisapride 50 mg/ml Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 5%/Ketoprofen 20%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Gabapentin 6%/Ketamine HCl 11.5%/Ketoprofen 10%/Lidocaine HCl 2% Topical Cream

Add

Adding

Radio 3

CheckboxCromolyn Sodium 100 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxClindamycin 150 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxCiprofloxacin 0.3%/Triamcinolone Acetonide 0.1% Otic Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 5%/Gabapentin 7.5%/Ketamine HCl 5.75%/Ketoprofen 5%/Lidocaine 1% Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar 10%/Salicylic Acid 10% Topical Ointment

Add

Adding

Radio 3

CheckboxCisapride 25 mg/ml Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxCyclobenzaprine 2%/Gabapentin 6%/Ketoprofen 10%/Lidocaine 2.5%/Prilocaine 2.5% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.23%/Diphenhydramine HCl 5%/Gabapentin 6%/Ketamine HCl 6.9%/Nifedipine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxClindamycin 1%/Spironolactone 5%/Tretinoin 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxClomipramine HCl 125 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxClonidine HCl 0.232%/Gabapentin 6%/Ketamine HCl 11.5%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxCreatine 500 mg/Lipoic Acid 20 mg/Ubiquinone 32 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCyclobenzaprine 4%/Ibuprofen 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxClioquinol 3%/Coal Tar 5%/Triamcinolone Acetonide 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxClonidine HCl 0.232%/Dextromethorphan HBr 2%/Nifedipine 2%/Verapamil HCl 6% Transdermal Gel

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Hydrocortisone 2% Topical Gel

Add

Adding

Radio 3

CheckboxCitalopram 60 mg/ml Sublingual Drops

Add

Adding

Radio 3

CheckboxClindamycin 50 mg/Hydrocortisone Acetate 90 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxClindamycin 1%/Ketoconazole 2%/Salicylic Acid 1% Topical Liquid

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxClindamycin HCl 1.09 mg/Gentamicin Sulfate 1.695 mg/Polymyxin B Sulfate 3000 units/mL Topical Liquid

Add

Adding

Radio 3

CheckboxClobetasol 17-Propionate 0.05%/Tretinoin 0.05% Oral Mouth Rinse Liquid

Add

Adding

Radio 3

CheckboxCoal Tar 5% Topical Ointment

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Diclofenac Sodium 5%/Glucosamine Sulfate 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxClindamycin Phosphate 2.376%/Erythromycin 2%/Metronidazole 0.75%/Salicylic Acid 2% Topical Gel

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxClopidogrel 75 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClonidine HCL 0.2%/Ketamine HCl 10%/Lidocaine HCl 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxCisapride 5 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxClobetasol 17-Propionate 0.05%/Niacinamide 2% Topical Cream

Add

Adding

Radio 3

CheckboxCyclosporine 1% Topical Cream

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Lidocaine HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxClotrimazole 3.5% Vaginal Gel

Add

Adding

Radio 3

CheckboxClonidine 0.1%/Dexamethasone 0.1%/Lidocaine 10%/Magnesium Sulfate 5%/Phenytoin 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxCisapride Monohydrate 5.2 mg/5 mL Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxClindamycin 200 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxClotrimazole 1%/Urea 20% Topical Ointment

Add

Adding

Radio 3

CheckboxCyclophosphamide 6 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 5%/Diclofenac Sodium 10%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxClioquinol 1%/Hydrocortisone 1% Otic Liquid

Add

Adding

Radio 3

CheckboxCoal Tar 1%/Fluocinonide 0.05% Topical Ointment

Add

Adding

Radio 3

CheckboxCoenzyme Q10 0.3%/Estriol 0.1%/Lipoic Acid 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxClonidine HCL 0.2%/Ketamine HCl 5.75%/Mexiletine HCl 2%/Phenytoin 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Gabapentin 6%/Ketamine HCl 15%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Ketoprofen 10%/Lidocaine HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Gabapentin 6%/Imipramine HCl 3%/Ketamine HCl 11.5%/Tetracaine 2% Topical Cream

Add

Adding

Radio 3

CheckboxClindamycin HCL 2.26%/Hydrocortisone 1%/Salicylic Acid 3% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Solution 5% Topical Shampoo

Add

Adding

Radio 3

CheckboxClonidine 0.2%/Gabapentin 6%/Ketamine 10%/Ketoprofen 10%/Lidocaine 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxCoal Tar Solution 10%/Clobetasol Propionate 0.05% Topical Ointment

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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