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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

CheckboxAmitriptyline HCl 8% Transdermal Gel

Add

Adding

Radio 3

CheckboxAzelaic Acid 20%/Niacinamide 4% Topical Cream

Add

Adding

Radio 3

CheckboxAtenolol 6.25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAripiprazole 1.5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 0.5% to 2%/Baclofen 0.5% to 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10%/Baclofen 2%/Cyclobenzaprine HCl 2%/Diclofenac Na 8%/Flurbiprofen 8%/Gabapentin 6% Topical Gel

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Adding

Radio 3

CheckboxAzithromycin 25 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAzelaic Acid 20%/Clindamycin HCl 2.26% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Niacinamide 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmphotericin B 100 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5%/Carbamazepine 2%/Diclofenac Sodium 10%/Gabapentin 6% Topical Gel

Add

Adding

Radio 3

CheckboxAnastrozole 0.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAtomoxetine 25 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAnthralin 1%/Salicylic Acid 5% Topical Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 3%/Clonidine HCl 0.2316%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 5% Gabapentin 3% Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Gabapentin 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmlodipine 0.5 mg/1 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAnthralin 0.2%/Salicylic Acid 5% Topical Ointment

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Adding

Radio 3

CheckboxAmitriptyline HCl 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5%/Bupivacaine HCl 2%/Gabapentin 5%/Ketoprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxAscorbic Acid 3%/Hydroquinone 5%/Kojic Acid 5%/Tretinoin 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxApomorphine HCl 2 mg Oral Troche

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 7%/Gabapentin 10%/Ketamine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxAscorbic Acid 2%/Hydroquinone 4%/Kojic Acid 2% Topical Gel

Add

Adding

Radio 3

CheckboxAzithromycin 200 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 100 mg/ml Veterinary Oral Liquid

Add

Adding

Radio 3

CheckboxAtenolol 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAnastrozole 0.1 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAzelaic Acid 5%/Clindamycin 2%/Niacinamide 4%/Tretinoin 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxAzelaic Acid 5%/Clindamycin 1%/Niacinamide 4% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 5%/Baclofen 2%/Ketoprofen 10%/Lidocaine HCL 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxAspirin 20 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxAzelaic Acid 6%/Hydrocortisone 1%/Hydroquinone 6%/Kojic acid 2%/Retinoic acid 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxArbutin 4%/Ascorbic Acid 20%/Glutathione 10%/Kojic Acid 4% Topical Cream

Add

Adding

Radio 3

CheckboxAmlodipine 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10%/Bupivacaine HCl 1%/Cyclobenzaprine 1%/Ketoprofen 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxAzathioprine 50 mg Oral Tablets (Gluten Free)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Ketoprofen 15% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 4%/Baclofen 2%/Bupivacaine HCl 2%/Clonidine HCl 0.2316%/Gabapentin 6%/Ketamine HCl 11.5%/Nifedipine 2% Topical Gel

Add

Adding

Radio 3

CheckboxAscorbic Acid 250 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxAtenolol 5 mg/0.1ml Transdermal Gel (Vet-Feline)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10%/Bupivacaine HCl 2.5%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Ketamine HCl 11.5%/Nifedipine 2.5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 1%/Lidocaine 2.5%/Meloxicam 0.09%/Prilocaine 2.5%/Tramadol HCl 0.25% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 50 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAtropine Sulfate 0.3 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAmlodipine Besylate 0.87 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxAmlodipine 0.625 mg/0.1 mL Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 100 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAnastrozole 1.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2.5%/Gabapentin 3%/Lidocaine 4.44%/Meloxicam 0.5%/Topiramate 1.25% Topical Ointment

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 4%/Diclofenac Na 4%/Gabapentin 8%/Ketamine HCl 13.8%/Lidocaine HCl 2.5%/Tramadol HCl 4% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5 mg/Baclofen 10 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 4%/Baclofen 2%/Ketamine HCl 11.5% Topical Gel

Add

Adding

Radio 3

CheckboxAmlodipine Besylate 0.87 mg/0.1 mL/Benazepril HCl 1.15 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxAmitrityline HCl 2%/Gabapentin 10%/Ketamine HCl 2.3%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Clobetasol Propionate 0.05%/Estriol 0.2% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Gabapentin 6%/Ketoprofen 15%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAtovaquone 62.5 mg/Proguanil HCl 25 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAtorvastatin 80 mg/15 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 100 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxArginine 800 mg Oral Capsules

Add

Adding

Radio 3

CheckboxArginine HCl 12.5% Topical Lotion

Add

Adding

Radio 3

CheckboxArbutin 10%/Glycolic Acid 4%/Hydrocortisone 0.5%/Hydroquinone 2%/Kojic Acid 4% Topical Gel

Add

Adding

Radio 3

CheckboxAnastrozole 1 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10 mg/Ketamine HCl 46 mg/Ketoprofen 50 mg/Lidocaine 10 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAzathioprine 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAmphotericin B 5 mg/Betamethasone 0.5 mg/Tobramycin 100 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5%/Cyclobenzaprine HCl 2%/Gabapentin 4%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmphotericin B 3% Vaginal Cream

Add

Adding

Radio 3

CheckboxArginine 5.33 g/30 mL/Creatine 1.33 g/30 mL/Glycine 2 g/30 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAnastrozole 1 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAnthralin 0.5% Topical Spray

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 50 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 10 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxAmphotericin B 125 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 4%/Baclofen 2%/Bupivacaine HCl 2%/Clonidine HCl 0.2316%/Gabapentin 6%/Ketamine HCl 11.5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5%/Dexamethasone 4%/Gabapentin 15%/Lidocaine 10% Topical Gel

Add

Adding

Radio 3

CheckboxAmphotericin 250 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Carbamazepine 2%/Piroxicam 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 1%/Lidocaine HCl 2.5%/Meloxicam 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxAnthralin 0.4 Topical Lotion

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Carbamazepine 2%/Ketoprofen 4% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 6%/Clonidine HCl 0.23%/Gabapentin 6%/Lidocaine 6%/Tetracaine HCl 4.55% Topical Gel

Add

Adding

Radio 3

CheckboxArbutin 3%/Niacinamide 5%/Tranexamic Acid 3% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Clonidine HCl 0.1%/Ketamine HCl 4.6%/Ketoprofen 10%/Lidocaine 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmphotericin B 40 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxAmpicillin 125 mg/Nystatin 10 000 IU Rectal Suppository

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 1%/Ketamine HCl 0.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 5%/Gabapentin 3%/Lidocaine HCl 5%/Triamcinolone 0.1% Transdermal Gel

Add

Adding

Radio 3

CheckboxAtenolol 2 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAnastrozole 0.5 mg/Clomiphene Citrate 25 mg Oral Troche

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAtropine Sulfate 0.25 mg/Morphine Sulfate 15 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxArginine 3400 mg/40 mL/Citrulline 1880 mg/40 mL Oral Liquid

Add

Adding

Radio 3

CheckboxApomorphine HCl 3 mg/Sildenafil 25 mg Oral Troche

Add

Adding

Radio 3

CheckboxAtomoxetine HCl 5 mg/ml Oral Liquid

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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