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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

CheckboxCarbidopa 25 mg/Levodopa 100 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxCalcium Gluconate 2% Topical Gel

Add

Adding

Radio 3

CheckboxCamphor 0.5%/Thymol 3% Nail Liquid

Add

Adding

Radio 3

CheckboxCaffeine Citrate 65 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCamphor 4%/Menthol 1%/Tetracaine HCl 3.414% Topical Liquid

Add

Adding

Radio 3

CheckboxCamphor 1%/Coal Tar Solution 3%/Resorcinol 5%/Zinc Oxide 15% Topical Ointment

Add

Adding

Radio 3

CheckboxCarbamazepine 2%/Gabapentin 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxCamphor 0.2%/Eucalyptol 0.2%/Menthol 0.2% Nasal Liquid

Add

Adding

Radio 3

CheckboxCefixime 100 mg/5 mL Oral Liquid (Dye Free)

Add

Adding

Radio 3

CheckboxCaffeine 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCarbidopa 25 mg/5 mL/Levodopa 250 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxCarbamazepine 2%/Gabapentin 6%/Imipramine HCl 3%/Loperamide HCl 3%/Ketamine HCl 11.5% Topical Gel

Add

Adding

Radio 3

CheckboxCarbamazepine 200 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxCalcium Carbonate 250 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCalcium Citrate 711 mg/Magnesium Citrate 619 mg/Zinc Sulfate 34.3 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCarisoprodol 175 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCabergoline 0.5 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxCaffeine 60 mg/Ketoprofen 25 mg/Magnesium Citrate 100 mg/Riboflavin 200 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCaffeine 1%/Minoxidil 7%/Tretinoin 0.25% Topical Liquid

Add

Adding

Radio 3

CheckboxCarbamazepine 4%/Doxepin 4%/Gabapentin 4%/Ketoprofen 4%/Lidocaine 1% Transdermal Gel

Add

Adding

Radio 3

CheckboxCarbamazepine 200 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCalcitriol 3 mcg/g Topical Ointment

Add

Adding

Radio 3

CheckboxCaffeine 100 mg/Chlorpheniramine Maleate 5 mg/Ginger 250 mg/Scopolamine Hydrobromide 0.3 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCarbamazepine 250 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxCarbidopa 25 mg/Levodopa 100 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxCamphor 0.5%/Ketoprofen 20%/Lidocaine 4%/Menthol 1% Topical Gel

Add

Adding

Radio 3

CheckboxCamphor 1% Topical Cream

Add

Adding

Radio 3

CheckboxCamphor 0.5%/Diclofenac Sodium 10%/Menthol 3.5% Transdermal Cream

Add

Adding

Radio 3

CheckboxCapecitabine 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCarisoprodol 3%/Ketoprofen 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxCefprozil 250 mg/5 mL Oral Liquid (Dye Free)

Add

Adding

Radio 3

CheckboxCaffeine 100 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCarbamazepine 100 mg/1 mL Transdermal Gel

Add

Adding

Radio 3

CheckboxCantharidin 1%/Podopyllum 5%/Salicylic Acid 30% Topical Liquid

Add

Adding

Radio 3

CheckboxCamphor 0.125%/Ibuprofen 5%/Menthol 0.125% Topical Gel

Add

Adding

Radio 3

CheckboxCabergoline 500 µg/mL Oral Liquid

Add

Adding

Radio 3

CheckboxCalcitriol 32 ng/mL Oral Liquid

Add

Adding

Radio 3

CheckboxCarvedilol 1.67 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCalcium Carbonate 1000 mg/Magnesium Oxide 500 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCalcium Carbonate 1500 mg/15 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxCarvedilol 3.125 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxCaffeine Citrate 20 mg/ml Oral Liquid (Gluten Free)

Add

Adding

Radio 3

CheckboxCaffeine 100 mg/Chlorpheniramine Maleate 2 mg/Scopolamine Hydrobromide 0.2 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCaptopril 50 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCaffeine 150 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxCamphor 1%/Clotrimazole 2%/Menthol 2%/Salicylic Acid 0.2% Topical Liquid

Add

Adding

Radio 3

CheckboxCamphor 0.5%/Menthol 3.5% Topical Gel

Add

Adding

Radio 3

CheckboxCarnitine L 250 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCaptopril 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxCaffeine 100 mg/Scopolamine Hydrobromide 0.3 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCalcium Gluconate 100 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxCamphor 0.5%/Hydrocortisone 1%/Menthol 0.5% Topical Lotion

Add

Adding

Radio 3

CheckboxCeftazidime 50 mg/ml Ophthalmic Liquid

Add

Adding

Radio 3

CheckboxCarbamazepine 100 mg/5 mL Oral Liquid (Gluten Free)

Add

Adding

Radio 3

CheckboxCarbamazepine 300 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxCaffeine 20 mg/Ketoprofen 37.5 mg/Magnesium Citrate 100 mg/Riboflavin 200 mg Oral Capsules

Add

Adding

Radio 3

CheckboxCamphor 0.25%/Glycerin 10%/Hydrocortisone 1%/Menthol 0.25% Topical Cream

Add

Adding

Radio 3

CheckboxCarbamazepine 5%/Ketamine HCl 2.3%/Ketoprofen 20%/Lidocaine HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxCantharidin 1% Topical Solution

Add

Adding

Radio 3

CheckboxCantharidin 1%/Podophyllum 5%/Salicylic Acid 25% Topical Liquid

Add

Adding

Radio 3

CheckboxCarbidopa 25 mg/Levodopa 100 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxBupropion HCl 150 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxBuspirone HCl 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBupropion HCl 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBupropion HCl 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBupropion HCl 50 mg/Liothyronine 5 mcg/Phentermine HCl 15 mg/Spironolactone 12.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxBupropion HCl 60 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBuprenorphine HCl 8.84 mg Oral Troche

Add

Adding

Radio 3

CheckboxBupropion HCl 75 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxButorphanol Tartrate 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBaclofen 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxBudesonide 1.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Diclofenac Sodium 3%/Tetracaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Diclofenac Sodium 3%/Gabapentin 6%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 4 mg/Diazepam 5 mg/Ketamine HCl 17.25 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxBupivacaine HCL 2/Ketamine HCL 5/Lidocaine HCL 2 Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Ketamine HCl 11.50%/Ketoprofen 10%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone 0.05%/Tretinoin 0.1%/Urea 40% Topical Ointment

Add

Adding

Radio 3

CheckboxBaclofen 2%/Gabapentin 8%/Ketamine HCl 5.75%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Ketamine HCl 11.5%/Ketoprofen 10%/Lidocaine HCl 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Bupivacaine HCl 1%/Diclofenac Sodium 3%/Gabapentin 6% Topical Gel

Add

Adding

Radio 3

CheckboxBudesonide 5 mg/Cromolyn Na 100 mg/Mesalamine 2670 mg/60 mL Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxBetahistine HCl 24 mg Oral Capsules

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 10%/Tetracaine 10% Topical Cream

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Ketoprofen 20%/Lidocaine HCl 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 10%/Ketoprofen 10%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Ketoprofen 10%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Lidocaine HCl 5%/Ketamine HCl 11.5%/Ketoprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Diclofenac Sodium 1.5%/Gabapentin 6%/Ketoprofen 3%/Pentoxifylline 5% Topical Gel

Add

Adding

Radio 3

CheckboxBeclomethasone Dipropionate 0.05% Oral Rinse

Add

Adding

Radio 3

CheckboxBupivicaine HCl 0.5%/Ketamine HCl 10% Topical Spray

Add

Adding

Radio 3

CheckboxBromocriptine 5 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxBaclofen 2%/Diclofenac Sodium 3%/Gabapentin 6%/Ketamine 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Sulfur 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 10 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxBumetanide 0.025 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBudesonide 0.0125%/Ketoconazole 0.3%/Vancomycin 0.4% Otic Liquid

Add

Adding

Radio 3

CheckboxBaclofen 2%/Ketoprofen 20%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBenazepril HCl 0.25 mg/0.1 mL Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxBudesonide 1 mg/60 mL/Sodium Butyrate 100 mM Rectal Enema Liquid

Directions:

QTY:

Refills

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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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