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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

CheckboxAscorbic Acid 5%/Hydrocortisone 1%/Hydroquinone 2% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 4%/Ketamine HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10 mg Rectal Suppository

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Adding

Radio 3

CheckboxAmitriptyline HCl 10 mg/5 mL Oral Liquid

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Adding

Radio 3

CheckboxAmitriptyline HCl 10%/Bupivacaine HCl 2.5%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Nifedipine 2.5% Topical Cream

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Adding

Radio 3

CheckboxArginine 375 mg Oral Capsules

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Adding

Radio 3

CheckboxApomorphine HCL 2.5 mg/ml/Phentolamine Mesylate 2.5 mg/ml Nasal Spray

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Adding

Radio 3

CheckboxAmitriptyline HCl 4%/Diclofenac Na 2%/Ketamine HCl 3.45%/Lidocaine HCl 5% Topical Gel

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Adding

Radio 3

CheckboxAzathioprine 8 mg Oral Capsules

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Adding

Radio 3

CheckboxApomorphine HCl 1 mg/Phentolamine Mesylate 2 mg/Tadalafil 10 mg Oral Capsules

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Adding

Radio 3

CheckboxAtenolol 6.25 mg Oral Tablets

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Adding

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CheckboxAnastrozole 0.1 mg/Clomiphene Citrate 12.5 mg/Pregnenolone 5 mg Oral Capsules

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Adding

Radio 3

CheckboxAnthralin 1%/Betamethasone Dipropionate 0.064%/Salicylic Acid 3% Topical Ointment

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Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Baclofen 2%/Gabapentin 5%/Ketoprofen 20%/Prilocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxAtomoxetine 18 mg Oral Troche

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Adding

Radio 3

CheckboxAmitriptyline HCl 1%/Diclofenac Na 8%/Gabapentin 6%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxAcetylcysteine 5% Ophthalmic Liquid

Add

Adding

Radio 3

CheckboxAcetylcysteine 10% Ophthalmic Liquid

Add

Adding

Radio 3

CheckboxAcetaminophen 250 mg/Caffeine 100 mg/Ergotamine Tartrate 1 mg/Prochlorperazine Maleate 4.05 mg Oral Capsules

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Adding

Radio 3

CheckboxAloe Vera 0.2%/Ketoprofen 2%/Lidocaine 2%/Misoprostol 0.0024%/Phenytoin Sodium 2% Topical Ointment

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Adding

Radio 3

CheckboxAcyclovir 5%/Lidocaine 2% Topical Gel

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Adding

Radio 3

CheckboxAcyclovir 2%/Urea 5% Topical Ointment

Add

Adding

Radio 3

CheckboxAmitriptyline 8%/Cyclobenzaprine 2%/Diclofenac 9%/DMSO 5%/Lido 4%/Menthol 2% Topical Ointment

Add

Adding

Radio 3

CheckboxAluminum Chloride 70% Topical Liquid

Add

Adding

Radio 3

CheckboxAcetaminophen 225 mg Oral Troche

Add

Adding

Radio 3

CheckboxAloe Vera 0.2%/Tea Tree Oil 5% Topical Cream

Add

Adding

Radio 3

CheckboxAminolevulinic Acid HCl 25.56% Topical Liquid

Add

Adding

Radio 3

CheckboxAloe Vera 1%/Diclofenac Na 12%/Lactic Acid 5%/Urea 40% Topical Cream

Add

Adding

Radio 3

CheckboxAmikacin 1%/Polymyxin B 5000 IU/mL Otic Liquid

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Adding

Radio 3

Checkbox7-Keto-Dehydroepiandrosterone 10 mg Oral Capsules

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Adding

Radio 3

CheckboxAcyclovir 5%/Amitriptyline HCl 1%/Ibuprofen 3%/Lidocaine 2.5%/Prilocaine 2.5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 2%/Gabapentin 6%/Ketamine 10%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAlprazolam 1 mg/Sertraline 50 mg Oral Capsules

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Adding

Radio 3

CheckboxAlbendazole 15% Topical Cream

Add

Adding

Radio 3

Checkbox5-Hydroxytryptophan 100 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAllantoin 3% Topical Ointment

Add

Adding

Radio 3

CheckboxAmantadine HCl 100 mg/ml Oral Liquid (Gluten Free)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Baclofen 2%/Bupivacaine HCl 0.5%/Piroxicam 3% Topical Gel

Add

Adding

Radio 3

CheckboxAloe Vera 5%/Glycolic Acid 1%/Niacinamide 2% Topical Liquid

Add

Adding

Radio 3

CheckboxAcetaminophen 300 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxAllantoin 3% Topical Cream

Add

Adding

Radio 3

CheckboxAcetic Acid 2%/Ketoconazole 2%/Terbinafine HCl 1%/Urea 2% Nail Lacquer

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 15%/Salicylic Acid 2% Topical Gel

Add

Adding

Radio 3

CheckboxAlprazolam 0.1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAminolevulinic Acid HCl 10% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 2%/Baclofen 2%/Gabapentin 3% Mucoadhesive Vaginal Cream

Add

Adding

Radio 3

CheckboxAcyclovir 200 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAcetazolamide 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAmantadine HCl 50 mg Slow Release (MEM4) Oral Capsules

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Adding

Radio 3

CheckboxAmitriptyline 3%/Gabapentin 3%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 30.6 mg/Budesonide 0.13 mg/Magnesium Hydroxide 40 mg/Simethicone 4 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAcetic Acid 10%/Lactic Acid 10%/Salicylic Acid 10% Topical Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 2%/Diclofenac Sodium 5%/Ketamine HCL 11.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAcetyl-L-Carnitine HCl 300 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAlbuterol 2 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline 5%/Gabapentin 5%/Ketamine 5%/Ketoprofen 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxAcetylcysteine 250 mg/Edetate Disodium 500 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 1%/Ketoprofen 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAcetaminophen 200 mg/Hydrocodone Bitartrate 15 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAcetylcysteine 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Ibuprofen 10%/Lidocaine HCl 5%/Orphenadrine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmantadine HCl 25 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAcebutolol HCl 100 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 2%/Gabapentin 2%/Ketoprofen 5%/Lidocaine HCL 5%/Tetracaine HCL 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxAllopurinol 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAcyclovir 3%/Carbamazepine 5%/Deoxy Glucose 0.2%/Ketamine HCl 2.3%/Ketoprofen 20%/Lidocaine HCl 4% Topical Gel

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Adding

Radio 3

CheckboxAcyclovir 400 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxAminolevulinic Acid HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxAcetyl Salicylic Acid 3 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAloe Vera 0.2%/Ketoprofen 2%/Lidocaine 2%/Misoprostol 0.0024%/Phenytoin Sodium 5% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline 4%/Clonidine 0.2%/Ketoprofen 10%/Lidocaine 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxAcetylcysteine 10%/Urea 5% Topical Lotion

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 70 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Amitriptyline HCl 5%/Deoxy Glucose 0.2%/Diphenhydramine HCl 2%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxAluminum Chloride 20% Topical Gel

Add

Adding

Radio 3

CheckboxAcetaminophen 160 mg/Caffeine 32.5 mg Oral Capsules

Add

Adding

Radio 3

Checkbox5-Fluorouracil 2%/Salicylic Acid 20% Topical Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Gabapentin 6%/Lidocaine HCl 0.5% Oral Rinse

Add

Adding

Radio 3

CheckboxAluminum Chloride 20%/Salicylic Acid 4% Topical Stick

Add

Adding

Radio 3

CheckboxAcetylcysteine 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmantadine HCl 8%/Amitriptyline HCl 5%/Baclofen 5%/Diclofenac Sodium 8%/Gabapentin 6%/Lidocaine 3% Topical Gel

Add

Adding

Radio 3

CheckboxAcetaminophen 250 mg/Acetylsalicylic Acid 150 mg/Caffeine 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAcetylsalicylic Acid 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAmiodarone HCl 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAllantoin 2%/Zinc Oxide 12% Topical Paste

Add

Adding

Radio 3

CheckboxAcetaminophen 250 mg/ml Topical Lotion

Add

Adding

Radio 3

CheckboxAcetic Acid 0.92% Vaginal Gel

Add

Adding

Radio 3

CheckboxAcyclovir 200 mg/5 mL Oral Liquid (Gluten Free)

Add

Adding

Radio 3

CheckboxAloe Vera 0.3%/Verapamil HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxAlpha Lipoic Acid 400 mg/7-Keto-Dehydroepiandrosterone 33.333 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAdenosyl Methionine 400 mg Oral Capsules

Add

Adding

Radio 3

Checkbox7- Keto DHEA 10 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

Checkbox4-Aminopyridine 10 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAluminum Chloride 30% Topical Gel

Add

Adding

Radio 3

CheckboxAloe Vera 0.05%/Caffeine 1%/Finasteride 0.1%/Minoxidil 10%/Tretinoin 0.025% Topical Foam

Add

Adding

Radio 3

CheckboxAmantadine HCl 0.25%/Baclofen 0.25%/Ketoprofen 1% Topical Gel

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 35 Topical Gel

Add

Adding

Radio 3

CheckboxAcetaminophen 500 mg/Butalbital 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAcyclovir 5%/2-Deoxy-D-Glucose 0.2%/Doxepin HCl 5.65%/Gabapentin 6%/Lidocaine HCl 5%/Orphenadrine Citrate 10% Topical 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

You may need to scale up or down your order form when printing to make it fit the page.

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