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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

CheckboxClomipramine HCl 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClindamycin Phosphate 4.752%/Tretinoin 0.25% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCL 0.23%/Gabapentin 6%/Ketamine HCL 10%/Nifedipine 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxCoal Tar 1%/Triamcinolone Acetonide 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxCyclobenzaprine 0.5%/Ketamine HCl 5%/Diclofenac Sodium 10%/Lidocaine 10% Topical Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1%/Ibuprofen 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxClonidine 0.2%/Gabapentin 6%/Ketamine 10%/Nifedipine 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine 2%/Gabapentin 10%/Ketamine 10%/Ketoprofen 10%/Lidocaine 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1%/Diclofenac Sodium 1%/Gabapentin 3%/Ibuprofen 10%/Tetracaine 2% Topical Gel

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05%/Fluocinolone Acetonide 0.01% Topical Lotion

Add

Adding

Radio 3

CheckboxClotrimazole 1%/Diphenhydramine 1%/Hydrocortisone 0.5%/Nystatin 100 MIU/g Topical Ointment

Add

Adding

Radio 3

CheckboxClomiphene Citrate 50 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxClotrimazole 10%/Urea 20% Topical Lotion

Add

Adding

Radio 3

CheckboxCoal Tar 5%/Salicylic Acid 10% Topical Ointment

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Ketamine HCl 11.5%/Ketoprofen 15%/Menthol 3% Topical Cream

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Gabapentin 6%/Ketoprofen 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1%/Ibuprofen 20%/Piroxicam 1% Transdermal Gel

Add

Adding

Radio 3

CheckboxClomiphene Citrate 25 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCyanocobalamin 1.2 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxClotrimazole 1%/Ibuprofen 3%/Menthol 3% Topical Liquid

Add

Adding

Radio 3

CheckboxClindamycin 2%/Dapsone 4%/Hydrocortisone 1%/Metronidazole 1% Topical Cream

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Hydrocortisone 1.25%/Mupirocin 1% Topical Cream

Add

Adding

Radio 3

CheckboxClotrimazole 1%/Fluocinolone Acetonide 0.01% Topical Lotion

Add

Adding

Radio 3

CheckboxClonidine HCl 0.025 mg Oral Capsules

Add

Adding

Radio 3

CheckboxClioquinol 1%/Hydrocortisone 1% Topical Cream

Add

Adding

Radio 3

CheckboxCyclophosphamide 25 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxCoal Tar Solution 5%/Salicylic Acid 10% Topical Ointment

Add

Adding

Radio 3

CheckboxClopidogrel 10 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxClonidine HCL 0.23%/Gabapentin 6%/Ketamine HCL 11.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine 0.5%/Diclofenac Sodium 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxClindamycin 2%/Hydrocortisone 1%/Salicylic Acid 3% Topical Cream

Add

Adding

Radio 3

CheckboxCoenzyme Q10 180 mg/5 mL Naso Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 10 mg/Gabapentin 50 mg/Ketoprofen 50 mg/Lidocaine 50 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxCisapride 10 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 3%/Ketoprofen 15%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxColchicine 0.5%/Hydroquinone 6% Topical Gel

Add

Adding

Radio 3

CheckboxClotrimazole 1% Mucoadhesive Oral Rinse

Add

Adding

Radio 3

CheckboxClomipramine HCl 2.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCyclosporine A 0.5% Topical Liquid

Add

Adding

Radio 3

CheckboxClindamycin 1%/Niacinamide 4%/Tretinoin 0.01% Topical Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine 3%/Diclofenac 10%/Lidocaine HCl 5%/Tetracaine HCl 3.414% Topical Gel

Add

Adding

Radio 3

CheckboxCyproheptadine HCl 120 mg/15 mL Oral Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2.0 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Gabapentin 5%/Ketoprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxCreatine 2.5 g/15 mL Oral Liquid

Add

Adding

Radio 3

CheckboxClotrimazole 10%/Urea 20% Topical Ointment

Add

Adding

Radio 3

CheckboxCiprofloxacin 0.3%/Miconazole 1%/Triamcinolone Acetonide 0.1% Otic Gel

Add

Adding

Radio 3

CheckboxClobetasol 17-Propionate 0.01%/Lidocaine HCl 1%/Miconazole 1% Mucoadhesive Oral Rinse

Add

Adding

Radio 3

CheckboxCyproheptadine HCl 2 mg Oral Capsules

Add

Adding

Radio 3

CheckboxClopidogrel 75 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxCiprofloxacin 0.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCodeine Phosphate 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClindamycin 1.2%/Tretinoin 0.025% Topical Cream

Add

Adding

Radio 3

CheckboxColchicine 0.6 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCoal Tar Solution 10%/Triamicinolone Acetonide 0.1% Topical Ointment

Add

Adding

Radio 3

CheckboxClobetasol 0.0225%/Zinc Pyrithione 0.1125% Topical Lotion

Add

Adding

Radio 3

CheckboxCyclobenzaprine 0.5%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Gabapentin 6%/Ketamine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxClopidogrel Bisulfate 13.05 mg/5mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxClindamycin HCl 1%/Mupirocin 2%/Zinc Oxide 25% Topical Ointment

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 5%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05%/Ketoconazole 2% Topical Liquid

Add

Adding

Radio 3

CheckboxClomipramine HCl 10 mg Oral Troches

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCL 0.5%/Diclofenac 2.7% Topical Gel

Add

Adding

Radio 3

CheckboxClindamycin 1%/Clobetasol Propionate 0.05% Topical Lotion

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 7.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Gabapentin 5%/Ketoprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.1% Topical Ointment

Add

Adding

Radio 3

CheckboxClindamycin 2%/Niacinamide 5%/Tretinoin 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 2%/Ketoprofen 15% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1%/Diclofenac Sodium 1%/Ibuprofen 10%/Tetracaine HCl 2.276% Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar Solution 5%/Urea 20%/Tretinoin 0.1% Topical Shampoo

Add

Adding

Radio 3

CheckboxCyproheptadine HCl 4 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05% Mouthwash Liquid

Add

Adding

Radio 3

CheckboxClomipramine HCl 2 mg/0.1 mL Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1%/Diclofenac Sodium 2%/Menthol 1% Transdermal Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.3%/Gabapentin 6%/Ketamine HCl 5%/Ketoprofen 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxClorazepate Dipotassium 3.75 mg/10 mL Oral Liquid

Add

Adding

Radio 3

CheckboxCoal Tar 2%/Pentoxifylline 5% Topical Cream

Add

Adding

Radio 3

CheckboxClonidine 0.1%/Gabapentin 6%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxCyclobenzaprine 2%/Diclofenac 3%/Flurbiprofen 3%/Gabapentin 10%/Lidocaine 3%/Tramadol 5% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.232%/Deoxy D-Glucose 0.5%/Gabapentin 6%/Ketamine HCl 11.5%/Lidocaine HCL 5% Topical Gel

Add

Adding

Radio 3

CheckboxCoenzyme Q10 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Doxepin HCl 5.65%/Ketamine HCl 5.75%/Ketoprofen 10%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxClindamycin HCl 40.72 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCyproheptadine HCl 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClindamycin 2%/Hydrocortisone1%/Salicylic Acid 3% Topical Lotion

Add

Adding

Radio 3

CheckboxCisapride 5 mg/ml Oral Liquid (Vet)

Add

Adding

Radio 3

CheckboxClonidine 0.2%/Diphenhydramine 10%/Gabapentin 6%/Ketoprofen 10%/Lidocaine 5% Topical Gel (Anhydrous)

Add

Adding

Radio 3

CheckboxCromolyn Sodium 200 mg Oral Capsules

Add

Adding

Radio 3

CheckboxClindamycin 0.6 mg/ml Nasal Irrigation Liquid

Add

Adding

Radio 3

CheckboxCiprofloxacin 1% Nasal Irrigation Liquid

Add

Adding

Radio 3

CheckboxCoal Tar 10%/Salicylic Acid 5% Topical Ointment

Add

Adding

Radio 3

CheckboxCodeine Phosphate 30 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxClomipramine HCl 3 mg Oral Capsules (Vet)

Add

Adding

Radio 3

CheckboxClonidine Hycrochloride 0.232%/Gabapentin 6%/Ketamine HCl 11.5%/Lidocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxCyclosporine 200 mg/g Vaginal Ointment

Add

Adding

Radio 3

CheckboxClindamycin 2%/Hydrocortisone 1%/Salicylic Acid 3% Topical Lotion

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.

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