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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

CheckboxBaclofen 1%/Gabapentin 3%/Ketamine HCl 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Bupivacaine HCl 1%/Diclofenac Sodium 5% Topical Gel

Add

Adding

Radio 3

CheckboxBudesonide 1 mg/5 mL Oral Viscous Slurry

Add

Adding

Radio 3

CheckboxBaclofen 2%/Ibuprofen 6%/Lidocaine 4%/Tramadol HCl 4% Topical Gel

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Adding

Radio 3

CheckboxBetaine HCl 187.5 mg Oral Capsules

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Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBiotin 0.05%/Caffeine 0.005%/Melatonin 0.003% Topical Foam

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Adding

Radio 3

CheckboxBaclofen 2%/Ketoprofen 20%/Lidocaine HCl 5%/Verapamil HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxBiotin 0.5 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Diclofenac Sodium 3%/Ketoprofen 10%/Lidocaine HCl 3% Topical Gel

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Adding

Radio 3

CheckboxBoric Acid 4% Otic Liquid

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Adding

Radio 3

CheckboxBaclofen 2%/Bupivacaine HCl 1%/Cyclobenzaprine HCl 2%/Diclofenac Sodium 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Bupivacaine HCL 1%/Cyclobenzaprine HCL 2%/Ketoprofen 10% Topical Gel

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Adding

Radio 3

CheckboxBaclofen 2%/Bupivacaine HCl 2.5%/Cyclobenzaprine HCL 2%/Diclofenac Sodium 8%/Gabapentin 6% Topical Gel

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Adding

Radio 3

CheckboxBudesonide 1 mg Slow Release (MEM4) Oral Capsules

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Adding

Radio 3

CheckboxBenzoyl Peroxide 3%/Clindamycin 1%/Niacinamide 4% Topical Cream

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Adding

Radio 3

CheckboxBudesonide 0.6 mg/2 mL/Itraconazole 40 mg/2 mL Nasal Spray

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Adding

Radio 3

CheckboxBudesonide 0.125 mg/ml/Mupirocin 1 mg/ml Nasal Gel

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Adding

Radio 3

CheckboxBetamethasone 1 mg/Clotrimazole 10 mg/Gentamicin 3 mg/ml Otic Liquid

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Adding

Radio 3

CheckboxBupivacaine HCl 1%/Misoprostol 0.0024%/Nifedipine 2%/Phenytoin 5% Topical Wound Dressing

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Adding

Radio 3

CheckboxBaclofen 3%/Ketamine HCl 3%/Ketoprofen 20% Transdermal Gel

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Adding

Radio 3

CheckboxBupivacaine HCl 0.1% Nasal Liquid

Add

Adding

Radio 3

CheckboxBaclofen 10%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxBupivacaine HCl 2%/Gabapentin 5%/Lidocaine HCl 7% Topical Gel

Add

Adding

Radio 3

CheckboxBacitracin 6 mg/Neomycin 3.6 mg/Nystatin 17 mg/Triamcinolone Acetonide 1 mg/g Topical Ointment

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Adding

Radio 3

CheckboxBacitracin 25 000 U/10 mL Oral Liquid

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Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2% Transdermal Gel

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Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.064%/Salicylic Acid 3% Topical Paste

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Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Clindamycin 1%/Tretinoin 0.01% Topical Lotion

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Adding

Radio 3

CheckboxBetamethasone Valerate 0.0085%/Mupirocin 0.1% Topical Cream

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 4%/Tetracaine 1% Topical Cream

Add

Adding

Radio 3

CheckboxBupivacaine HCl 3%/Ketamine HCl 5.75%/Ketoprofen 10%/Prilocaine HCl 5% Topical Cream

Add

Adding

Radio 3

CheckboxBaclofen 2%/Clonidine HCl 0.2%/Gabapentin 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Clindamycin 1%/Salicylic Acid 5% Topical Lotion

Add

Adding

Radio 3

CheckboxBaclofen 5 mg Vaginal Suppository

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Adding

Radio 3

CheckboxBenzoyl Peroxide 20%/Erythromycin 4% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 10 mg/Diazepam 2.5 mg/Lidocaine 50 mg Vaginal Suppository

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBaclofen 2%/Gabapentin 6%/Ketamine HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Ketoprofen 20%/Tetracaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.13%/Clotrimazole 2% Otic Drops

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Adding

Radio 3

CheckboxBenztropine Mesylate 0.5 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxBaclofen 1%/Cyclobenzaprine HCl 2%/Ketoprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone 0.6 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Ketoprofen 20%/Lidocaine HCl 2.5% Topical Gel

Add

Adding

Radio 3

CheckboxBelladonna Extract 16.2 mg/Morphine Sulfate 7.5 mg Rectal Suppository

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 6% Plasticized Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Ketoprofen 15%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Ketoprofen 20%/Lidocaine HCl 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxBenztropine Mesylate 2 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxBaclofen 2%/Ketoprofen 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBuprenorphine Hydrochloride 1.62 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxBupivacaine HCl 2%/Clonidine HCl 0.22%/Gabapentin 10%/Ketamine HCl 5.75% Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Gabapentin 6%/Ketoprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Diclofenac Sodium 3%/Tetracaine HCl 2.27% Topical Gel

Add

Adding

Radio 3

CheckboxBupivacaine HCl 0.5%/Ketoprofen 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Clonidine HCl 0.2%/Ketamine HCl 11.5%/Ketoprofen 20%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Ketamine HCl 11.5%/Ketoprofen 15%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.1%/Ketotifen Fumarate 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxBiotin 35 mg/5 mL/Thiamine HCl 250 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxBaclofen 2%/Ibuprofen 6%/Tramadol HCl 4% Topical Gel

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Topical Cream

Add

Adding

Radio 3

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

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCL 2%/Gabapentin 6%/Ketamine HCL 11.5%/Lidocaine HCL 5% Transdermal Gel

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Plasticized Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 5%/Ketoprofen 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxBenzocaine 12% Otic Liquid

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBupivacaine HCl 0.75%/Ketoprofen 15% Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 1%/Diclofenac Sodium 5%/Gabapentin 3% Transdermal Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Ibuprofen 3%/Lidocaine HCl 3% Topical Gel

Add

Adding

Radio 3

CheckboxBuprenorphine 2 mg/0.1 mL Nasal Spray

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.04%/Mupirocin 0.66%/Nystatin 33333 IU/g Topical Cream

Add

Adding

Radio 3

CheckboxBaclofen 6%/Clonidine HCl 0.2%/Diclofenac Sodium 3%/Gabapentin 6%/Lidocaine 2.5% Topical Gel

Add

Adding

Radio 3

CheckboxBalsalazide Disodium 750 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxBaclofen 2%/Gabapentin 5%/Lidocaine HCl 2.5%/Nifedipine 2%/Tramadol HCl 3% Transdermal Gel

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 10%/Tetracaine 10% Plasticized Gel

Add

Adding

Radio 3

CheckboxBaclofen 4%/Gabapentin 8%/Ketoprofen 6%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Gabapentin 6%/Ketoprofen 6%/Lidocaine 2%/Prilocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 5%/Gabapentin 6%/Ketoprofen 10%/Lidocaine HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxBupivacaine HCL 1%/Diclofenac Sodium 8% Topical Gel

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBaclofen 2% Vaginal Gel

Add

Adding

Radio 3

CheckboxBaclofen 5 mg/5 mL Gastric Tube Liquid

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Adding

Radio 3

CheckboxBaclofen 2%/Gabapentin 6%/Ketamine 10%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxBeclomethasone Dipropionate 0.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBicalutamide 50 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxBetahistine HCl 8 mg Oral Capsules

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Sulfur 2.5% Topical Gel

Add

Adding

Radio 3

CheckboxBetahistine HCl 16 mg Oral Capsules

Add

Adding

Radio 3

CheckboxBaclofen 2%/Gabapentin 5%/Lidocaine HCl 2.5%/Prilocaine HCl 2%/Tramadol HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.064%/Clotrimazole 1% Topical Lotion

Add

Adding

Radio 3

CheckboxBaclofen 2%/Bupivacaine HCL 2%/Cyclobenzaprine HCL 2%/Diclofenac Sodium 3%/Gabapentin 10% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.064%/Miconazole 2%/Mupirocin 1% Topical Ointment

Add

Adding

Radio 3

CheckboxBupivacaine HCl 0.5%/Ketamine HCl 1%/Ketoprofen 10% Transdermal Gel

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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