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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

CheckboxAluminum Chloride 10%/Glutaraldehyde 2%/Glycopyrrolate 1% Topical Gel

Add

Adding

Radio 3

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

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Adding

Radio 3

CheckboxAcetaminophen 200 mg/Hydrocodone Bitartrate 7.5 mg Oral Capsules

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Adding

Radio 3

CheckboxAcetazolamide 125 mg Oral Capsules (Gluten Free)

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Adding

Radio 3

CheckboxAloe Vera 0.5%/Clindamycin 1%/Hydrocortisone 1%/Spironolactone 5%/Vitamin E Acetate 5% Topical Cream

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Adding

Radio 3

CheckboxAmantadine HCl 2%/Lidocaine 4.6%/Meloxicam 0.5%/Topiramate 1.25%/Tramadol HCl 2% Topical Gel

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Adding

Radio 3

Checkbox2-Deoxy-D-Glucose 2% Topical Cream

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Adding

Radio 3

CheckboxAcepromazine Maleate 1 mg/ml Transdermal Gel

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Adding

Radio 3

CheckboxAcetic Acid 2%/Hydrocortisone 2% Otic Drops

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Adding

Radio 3

CheckboxAmitriptyline 2%/Clonidine 0.2%/Ketoprofen 10%/Lidocaine 10% Transdermal Gel

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Adding

Radio 3

CheckboxAcyclovir 5%/Amitriptyline HCl 5%/Gabapentin 5%/Lidocaine HCl 5% Topical Gel

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Adding

Radio 3

CheckboxAcetylcysteine 600 mg Oral Capsules (Gluten Free)

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Adding

Radio 3

CheckboxAloe Vera 0.2%/Tacrolimus 0.03% Topical Shampoo

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Adding

Radio 3

CheckboxAcyclovir 2%/Levofloxacin 1%/Metronidazole 1%/Mupirocin 2% Topical Gel

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Adding

Radio 3

CheckboxAmantadine HCl 10%/Diclofenac Sodium 8%/Gabapentin 6%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 2%/Diclofenac Sodium 5%/Ketoprofen 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxAcetaminophen 50 mg/Hydrocodone Bitartrate 10 mg Oral Capsules

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Adding

Radio 3

CheckboxAcetyl L Carnitine 500 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxAmitriptyline HCL 1%/Ketoprofen 5%/Tetracaine HCL 2% Transdermal Gel

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Adding

Radio 3

CheckboxAcetic Acid 0.2%/Clotrimazole 0.1%/Hydrocortisone 0.1% Otic Liquid

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Adding

Radio 3

CheckboxAmantadine HCl 8%/Amitriptyline HCl 4%/Baclofen 2%/Bupivacaine HCl 2%/Clonidine HCl 0.232%/Gabapentin 6%/Nifedipine 2% Topical Gel

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Baclofen 2%/Clonidine HCl 0.2316%/Gabapentin 5%/Ketamine HCl 5.75%/Ketoprofen 10%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxAluminum Chloride 20%/Salicylic Acid 4% Topical Gel

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Adding

Radio 3

CheckboxAmiloride HCl 1.5 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxAmitriptyline 2%/Baclofen 2%/Clonidine 0.23%/Ibuprofen 5%/Ketamine 5.75%/Ketoprofen 5%/Lidocaine 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Baclofen 2%/Gabapentin 5%/Ketamine HCl 11.5%/Lidocaine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Baclofen 4%/Diclofenac Na 6%/Ibuprofen 6%/Lidocaine HCL 4% Topical Gel

Add

Adding

Radio 3

CheckboxAcetaminophen 400 mg/Tramadol HCl 40 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline 2%/Baclofen 2%/Clonidine 0.23%/Ibuprofen 5%/Ketamine 5.75%/Ketoprofen 5%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

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

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Adding

Radio 3

Checkbox5-Hydroxytryptophan 50 mg/100 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAminocaproic Acid 500 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAmitriptyline 5%/Camphor 2%/Cyclobenzaprine 5%/Doxepin 2%/Gaba 5%/Keto 10%/Lido 5%/Menthol 2%/Tramadol 5% Topical Cream

Add

Adding

Radio 3

CheckboxAlprazolam 0.25 mg/ml Oral Liquid

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Adding

Radio 3

CheckboxAloe Vera 0.5%/Biotin 0.1%/Dehydroepiandrosterone 2%/Glycolic Acid 5%/Lipoic Acid 2% Topical Gel

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Adding

Radio 3

Checkbox4-Aminopyridine 5 mg Oral Capsules

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Adding

Radio 3

CheckboxAminocaproic Acid 5% Mouth Rinse Liquid

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Adding

Radio 3

CheckboxAmitriptyline 5%/Ketamine 1%/Ketoprofen 5%/Lidocaine 1% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 5%/Clonidine 0.5%/Diclofenac 5%/Gabapentin 6%/Ketamine 8%/Lidocaine 8% Transdermal Gel

Add

Adding

Radio 3

Checkbox5-Hydroxytryptophan 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 80 mg/Cimetidine 1.2 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline 2%/Baclofen 2%/Clonidine 0.1%/Gabapentin 6%/Ketamine 10% Transdermal Gel

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 35% Topical Liquid

Add

Adding

Radio 3

CheckboxAcyclovir 800 mg Oral Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Amitriptyline HCl 2%/Ketamine HCl 11.5%/Ketoprofen 10%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

Checkbox7-Keto-Dehydroepiandrosterone 200 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAcebutolol HCl 400 mg/5 mL Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxAminolevulinic Acid HCl 20% Topical Ointment

Add

Adding

Radio 3

CheckboxAcyclovir 2%/Amitriptyline HCl 2%/Ketoprofen 15%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxAminolevulinic Acid HCl 20% Topical Liquid

Add

Adding

Radio 3

CheckboxAllantoin 2%/Coal Tar Solution 5%/Hydrocortisone 0.5% Topical Lotion

Add

Adding

Radio 3

CheckboxAloe Vera 0.2%/Lidocaine HCl 2%/Metronidazole 2%/Pentoxifylline 5%/Phenytoin Sodium 5% Topical Cream

Add

Adding

Radio 3

CheckboxAcyclovir 4%/Amitriptyline HCl 2%/Bupivacaine HCl 1%/2-Deoxy-D-Glucose 2%/Flurbiprofen 5%/Gabapentin 10% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 5%/Gabapentin 5%/Ketamine 7% Transdermal Gel

Add

Adding

Radio 3

CheckboxAcetaminophen 80 mg Oral Popsicles

Add

Adding

Radio 3

CheckboxAmikacin 2.5% Ophthalmic Liquid

Add

Adding

Radio 3

CheckboxAmikacin 250 mg/ml/Budesonide 0.6 mg/ml/Clarithromycin 125 mg/ml Nasal Gel

Add

Adding

Radio 3

CheckboxAloe Vera 1%/Ascorbic Acid 15%/Glycolic Acid 5% Topical Cream

Add

Adding

Radio 3

CheckboxAcetaminophen 100 mg/Hydrocodone Bitartrate 10 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline 4/Baclo 2/Bupivacaine 2/Clonidine 0.232/Diclo 4/Gabapentin 6/Keta 6.9/Nifedipine 3 Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 2%/Baclofen 4%/Clonidine 0.2%/Gabapentin 5%/Ketamine 11.5%/Ketorolac Tromethamine 10%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

Checkbox7-Keto-Dehydroepiandrosterone 25 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxAcetyl-L-Carnnitine HCl 500 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 2%/Cyclobenzaprine HCL 0.5%/Piroxicam 0.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAcetaminophen 200 mg/Hydrocodone Bitartrate 10 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAcetyl Salicylic Acid 20%/Betamethasone Dipropionate 0.064%/Salicylic Acid 3% Topical Ointment

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 1%/Clonidine HCl 0.116%/Gabapentin 3%/Ketoprofen 5%/Lidocaine HCl 3% Transdermal Gel

Add

Adding

Radio 3

Checkbox5-Hydroxytryptophan 5 mg Oral Sublingual Troche

Add

Adding

Radio 3

CheckboxAmitriptyline 10%/Cyclobenzaprine HCl 0.5%/Ketoprofen 20% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 5%/Cyclobenzaprine 5%/Gabapentin 5%/Ketoprofen 10%/Lidocaine 5%/Tramadol 5% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 2%/Clonidine HCL 0.1%/Gabapentin 3%/Ketoprofen 5%/Tetracaine 2% Transdermal Gel

Add

Adding

Radio 3

CheckboxAcyclovir 3% Ophthalmic Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline 10%/Ketamine 5%/Lidocaine 5%/Prilocaine 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAlbendazole 30 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAmitriptyline 2%/Baclofen 4%/Clonidine 0.2%/DMSO 5%/Gabapentin 5%/Ketamine 10%/Lidocaine 5% Transdermal Gel

Add

Adding

Radio 3

Checkbox5-Hydroxytryptophan 50 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 4%/Baclofen 2%/Bupivacaine HCl 2% Clonidine HCl 0.2316%/Gabapentin 6%/Ketamine HCl 1.15%/Nifedipine 2% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 5%/Ketamine HCL 5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmantadine HCl 3%/Carbamazepine 3%/Doxepin HCl 5%/Gabapentin 6%/Guaifenesin 5%/Ketamine HCl 11.5%/Pentoxifylline 3%/Piroxicam 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Hydrocortisone 2% Topical Cream

Add

Adding

Radio 3

CheckboxAcetic Acid 5% Iontophoresis Liquid

Add

Adding

Radio 3

CheckboxAcetaminophen 325 mg/Oxycodone HCl 5 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAcetylcysteine 5%/Nicotinamide 2% Topical Cream

Add

Adding

Radio 3

CheckboxAcetylcysteine 200 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxAlendronate Sodium 91 mg/75 mL Oral Liquid

Add

Adding

Radio 3

CheckboxAcetaminophen 300 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAmiodarone HCl 5 mg/ml Oral Liquid

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxAmitriptyline HCL 2%/Gabapentin 6%/Ketamine HCL 15%/Ketoprofen 5%/Lidocaine 3.5%/Prilocaine HCL 3.5% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 7%/Gabapentin 10%/Ketamine 5.75% Transdermal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2/Carbamazepine 2/Clonidine HCl 0.23/Ketoprofen 10 Transdermal Gel

Add

Adding

Radio 3

CheckboxAcetaminophen 300 mg/ml Topical Lotion

Add

Adding

Radio 3

CheckboxAmantadine HCl 5%/Gabapentin 5%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 8%/Cyclobenzaprine 2%/Diclofenac 10%/DMSO 6%/Lidocaine 4%/Menthol 5% Topical Ointment

Add

Adding

Radio 3

CheckboxAloe Vera 0.2%/Ketoprofen 2%/Lidocaine 2% Topical Ointment

Add

Adding

Radio 3

Checkbox4-Aminopyridine 5 mg Slow Release (MEM4) Oral Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline 20%/Ketamine 10%/Lidocaine 10%/Prilocaine 10% Topical Gel

Add

Adding

Radio 3

Checkbox5-Hydroxytryptophan 100 mg/ml Oral Sublingual Drops

Add

Adding

Radio 3

CheckboxAcetaminophen 325 mg/Dichloralphenazone 100 mg/Isometheptene Mucate 65 mg Oral Capsules

Add

Adding

Radio 3

CheckboxAmantadine HCl 10 mg/ml Oral Liquid (Gluten Free)

Directions:

QTY:

Refills

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2

3

4

5

6

7

8

9

10

xPrescriber's Signature:

Date

3

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Fill out the Pharmacy Name and Fax Number, then fax it to the Pharmacy.

Pharmacy Name

Pharmacy Fax Number

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