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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

CheckboxBetamethasone 0.05%/Miconazole Nitrate 2%/Mupirocin 1% Topical Ointment

Add

Adding

Radio 3

CheckboxBuprenorphine 0.3 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBuprenorphine HCl 2 mg Oral Troche

Add

Adding

Radio 3

CheckboxBumetanide 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBisoprolol Fumarate 1.25 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxBiotin 0.1%/Minoxidil 5% Topical Foam

Add

Adding

Radio 3

CheckboxBudesonide 1 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxBaclofen 2%/Diclofenac Sodium 3%/Verapamil HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxBenazepril HCl 0.65 mg/0.5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxBudesonide 1.5 mg/Ciprofloxacin 90 mg/Clotrimazole 10 mg Oral Capsule (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxBenzocaine 20 mg/60 mL/Docusate Sodium 283 mg/60 mL Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxBaclofen 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 8%/Tetracaine 8% Plasticized Gel

Add

Adding

Radio 3

CheckboxBudesonide 9 mg Rectal Suppository

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBaclofen 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxBetamethasone Sodium Phosphate 6.25 mg/ml Oral Rinse

Add

Adding

Radio 3

CheckboxBeclomethasone Dipropionate 3 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxBaclofen 20 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxBaclofen 2%/Diclofenac Sodium 4%/Lidocaine 4%/Verapamil HCl 8% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Gabapentin 4%/Ketamine HCl 11 5%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxBisacodyl 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBaclofen 1%/Cyclobenzaprine HCl 1%/Gabapentin 3%/Ketoprofen 10%/Lidocaine HCl 4% Topical Gel

Add

Adding

Radio 3

CheckboxBudesonide 2 mg/60 mL/Mesalamine 1 g/60 mL Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.032%/Clotrimazole 2.5%/Mupirocin 0.5%/Nystatin 25/000 IU/g Topical Ointment

Add

Adding

Radio 3

CheckboxBaclofen 2%/Diazepam 1%/Gabapentin 6%/Hydrocortisone 2%/Ketamine HCl 1.15% Vaginal Gel

Add

Adding

Radio 3

CheckboxBuprenorphine HCl 0.324 mg/ml Oral Liquid

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBetamethasone Sodium Phosphate 6.6 mg/100 mL Rectal Enema Liquid

Add

Adding

Radio 3

CheckboxBetahistine HCl 8 mg/0.1 mL Nasal Spray

Add

Adding

Radio 3

CheckboxBenazepril HCl 5 mg/0.1 mL Transdermal Gel (Vet)

Add

Adding

Radio 3

CheckboxBetamethasone 0.05%/Tretinoin 0.05%/Verapamil HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxBupivacaine HCl 0.5%/Gabapentin 8%/Ketoprofen 20% Topical Gel

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxBuprenorphine 2 mg/Naltrexone HCl 0.5 mg/ml Oral Sublingual Drops

Add

Adding

Radio 3

CheckboxBenzocaine 400 mg/Lidocaine 120 mg/Tetracaine 80 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxBetamethasone 0.1%/Itraconazole 1% Otic Liquid

Add

Adding

Radio 3

CheckboxBenzocaine 20% Oral Mouth Rinse

Add

Adding

Radio 3

CheckboxBaclofen 5%/Diclofenac 10%/Ketamine HCl 11.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 8%/Tetracaine 4% Plasticized Gel

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 4%/Salicylic Acid 4% Topical Cream

Add

Adding

Radio 3

CheckboxBaclofen 1 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxBaclofen 2%/Bupivacaine HCl 1%/Diclofenac Sodium 5%/Verapamil HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 30 mg/Gabapentin 120 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 8%/Tetracaine 4% Topical Cream

Add

Adding

Radio 3

CheckboxBacitracin 50 000 IU/L Nasal Irrigation Liquid

Add

Adding

Radio 3

CheckboxBetamethasone 0.1%/Finasteride 0.5%/Minoxidil 8% Topical Lotion

Add

Adding

Radio 3

CheckboxBoric Acid 600 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxBetahistine HCl 8 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBrompheniramine Maleate 12 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxBuprenorphine HCl 0.864 mg/ml Sublingual Liquid

Add

Adding

Radio 3

CheckboxBaclofen 2%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 4%/Estriol 0.01%/Gabapentin 6% Vaginal Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 5%/Cyclobenzaprine HCL 2%/Piroxicam 1% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 0.5%/Estriol 0.03% Transdermal Gel

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Clindamycin 1%/Tretinoin 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxAzithromycin Dihydrate 1.0% Ophthalmic Liquid

Add

Adding

Radio 3

CheckboxAzathioprine 4 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAnthralin 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 50 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAmlodipine 5 mg/5mL/Benazepril HCl 10 mg/5mL Oral Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Diclofenac Sodium 3% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg/Baclofen 20 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxAtropine Sulfate 7.8 mcg/Hyoscyamine Sulfate 41.5 mcg/Scopolamine HBr 2.6 mcg/mL Oral Liquid

Add

Adding

Radio 3

CheckboxAmphotericin B 3% Topical Cream

Add

Adding

Radio 3

CheckboxAspirin 80 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2% Vaginal Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Ketamine HCl 1.15% Vaginal Cream

Add

Adding

Radio 3

CheckboxAtenolol 5 mg/ml Naso Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxArginine 6%/Papaverine HCl 3% Topical Cream

Add

Adding

Radio 3

CheckboxAmphotericin B 100 mcg/mL Nasal Irrigation Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5%/Ketamine HCl 5.75%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxAtomoxetine HCl 40 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 50 mg/ml Sublingual Drops

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Ivermectin 1%/Metronidazole 1% Topical Cream

Add

Adding

Radio 3

CheckboxAmitritpyline 2%/Carbamazepine 5%/Gabapentin 8%/Ketamine 5.75%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5%/Ketoprofen 15%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 1%/Tetracaine HCl 2% Vaginal Cream

Add

Adding

Radio 3

CheckboxAnastrozole 0.5 mg Oral Troche

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 3%/Baclofen 0.76%/Ketamine HCl 1.725% Transdermal Gel

Add

Adding

Radio 3

CheckboxAzithromycin 40 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 7.5/Ketamine HCl 5.75/Ketoprofen 10/Lidocaine 5 Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 3%/Lidocaine HCl 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxArginine HCl 4 g/2 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAmphotericin B 0.25% Nasal Spray

Add

Adding

Radio 3

CheckboxApomorphine HCl 1 mg/Phentolamine Mesylate 2 mg/Tadalafil 20 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Kojic Acid 6%/Tranexamic Acid 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10 mg/Ketamine HCl 10 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAscorbic Acid 2%/Glycolic Acid 8%/Hydroquinone 5%/Tranexamic Acid 2% Topical Gel

Add

Adding

Radio 3

CheckboxAtropine Sulfate 1% Sublingual Drops

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 1%/Clobetasol Propionate 0.05%/Ketoconazole 1% Oral Rinse

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Ketoprofen 10%/Magnesium Chloride 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxAtropine Sulfate 0.01% Oral Rinse

Add

Adding

Radio 3

CheckboxAzelaic Acid 5%/Minoxidil 7.5%/Pyridoxine HCl 1% Topical Lotion

Add

Adding

Radio 3

CheckboxAmphotericin B 25 mg/Nystatin 250 000 IU Oral Capsules

Add

Adding

Radio 3

CheckboxAzithromycin 75 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Lidocaine HCl 0.5% Oral Rinse

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 25 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAspirin 325 mg/Butalbital 50 mg/Caffeine 40 mg/Codeine Phosphate 30 mg Rectal Suppository

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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