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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.

First

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1

Circle for steps.

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

Circle for steps.

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

CheckboxZinc Sulfate 0.025% Mouth Rinse

Add

Adding

Radio 3

CheckboxZinc Pyrithione 1%/Ketoconazole 1% Shampoo

Add

Adding

Radio 3

CheckboxZinc Pyrithione 2% Topical Gel

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Clobetasol Propionate 0.05%/Cyanocobalamin 0.07% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Sulfate 1%/Aluminum Sulfate 5% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Cyanocobalamin 0.07%/Clobetasol Propionate 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Cyanocobalamin 0.07% Topical Gel

Add

Adding

Radio 3

CheckboxZinc Gluconate 100 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxZinc Oxide 5%/Aloe Vera Oil 2%/Vitamin A Palmitate 5000 IU/ml/Vitamin E Acetate 0.1% Topical Liquid

Add

Adding

Radio 3

CheckboxZinc Oxide 10%/Hydroxyquinoline Sulfate Topical Ointment

Add

Adding

Radio 3

CheckboxZinc Oxide 3% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Gluconate 1%/Chlorhexidine Gluconate 0.14% Dental Gel (Vet)

Add

Adding

Radio 3

CheckboxZinc Oxide 5%/Mupirocin 2%/Nystatin 100,000 Units/Gm Topical Gel

Add

Adding

Radio 3

CheckboxZinc Oxide 12.5%/Lidocaine 5%/Pramoxine HCl 1% Topical/Rectal Gel

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Clobetasol Propionate 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Clobetasol Propionate 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxZinc Oxide 5%/Camphor 1%/Phenol 1.87%/Boric Acid 2% Rectal Ointment

Add

Adding

Radio 3

CheckboxZinc Oxide 10%/Aluminum Hydroxide 2.5% Topical Ointment

Add

Adding

Radio 3

CheckboxZinc Oxide 20%/Cholestyramine 5% Topical Ointment

Add

Adding

Radio 3

CheckboxZinc Oxide 10%/Hydrocortisone 1%/Lidocaine 1% Topical/Rectal Gel

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2% Shampoo

Add

Adding

Radio 3

CheckboxZinc Oxide 8%/Cholestyramine 4%/Miconazole 2%/Mupirocin 2% Topical Gel

Add

Adding

Radio 3

CheckboxZinc Gluconate 0.5%/Amino Acid Topical Lotion (Vet)

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2% Topical Spray

Add

Adding

Radio 3

CheckboxZinc Gluconate 0.5% Nasal Spray

Add

Adding

Radio 3

CheckboxZinc 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxXylometazoline HCl 0.05% Nasal Solution

Add

Adding

Radio 3

CheckboxZidovudine 20 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxZinc Acetate 1% Topical Solution

Add

Adding

Radio 3

CheckboxZinc Chloride 1% Topical Solution

Add

Adding

Radio 3

CheckboxXylometazoline HCl 0.1% Nasal Solution

Add

Adding

Radio 3

CheckboxXylitol 66.7% Oral Gel

Add

Adding

Radio 3

CheckboxXylitol 66.7% Oral Syrup

Add

Adding

Radio 3

CheckboxZinc Acetate 0.5%/Boric Acid 1% Topical Solution

Add

Adding

Radio 3

CheckboxXylitol 60% Oral Syrup

Add

Adding

Radio 3

CheckboxVitamin E 200 U/Gm Vaginal Gel

Add

Adding

Radio 3

CheckboxXylitol 3% Mouthwash

Add

Adding

Radio 3

CheckboxVoriconazole 1% Ophthalmic Solution (Pf)

Add

Adding

Radio 3

CheckboxVitamin E Acetate 100 U/ml/Coenzyme Q-10 15 mg/ml/Beta Carotene 1249 IU/ml Oral Suspension

Add

Adding

Radio 3

CheckboxWarfarin Sodium 5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxWarfarin Sodium 10 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxXylitol 7% Oral Rinse

Add

Adding

Radio 3

CheckboxWarfarin Sodium 7.5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxXylitol 40% Oral Syrup

Add

Adding

Radio 3

CheckboxWarfarin Sodium 1 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxVitamin E Acetate 200 U/ml Vaginal Cream

Add

Adding

Radio 3

CheckboxWarfarin Sodium 2.5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxVitamin E 400 IU Vaginal Suppository

Add

Adding

Radio 3

CheckboxVerapamil HCl 60 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxVerapamil HCl 10%/Magnesium Chloride Hexahydrate 10% Topical Gel

Add

Adding

Radio 3

CheckboxVerapamil HCl 100 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxVerapamil HCl 10%/Diclofenac Sodium 5% Topical Gel

Add

Adding

Radio 3

CheckboxVitamin E 100 IU Vaginal Suppository

Add

Adding

Radio 3

CheckboxVerapamil HCl 50 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxVerapamil HCl 240 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxVerapamil HCl 15% Topical Gel

Add

Adding

Radio 3

CheckboxVitamin A/D/E Suppository

Add

Adding

Radio 3

CheckboxVitamin E 200 IU Vaginal Suppository

Add

Adding

Radio 3

CheckboxVerapamil HCl 180 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxVerapamil HCl 40 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxVerapamil HCl 120 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxVerapamil HCl 10%/Pentoxifylline 5% Topical Gel

Add

Adding

Radio 3

CheckboxVancomycin 200 mg/Amphotericin B 5 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVancomycin 250 mg/Gm/Mupirocin 2% Otic Gel

Add

Adding

Radio 3

CheckboxVancomycin 160 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVancomycin 200 mg/Tobramycin 100 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVancomycin 500 mg/60 ml/Metronidazole 250 mg/60 ml Rectal Suspension Enema

Add

Adding

Radio 3

CheckboxVancomycin 50 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxVancomycin 160 mg/Mometasone Furoate 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVancomycin 50 mg/Mupirocin 20 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVancomycin 200 mg/Tobramycin 125 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVerapamil HCl 10%/Diclofenac Sodium 5%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxVancomycin 250 mg/Gm Otic Gel

Add

Adding

Radio 3

CheckboxVancomycin 200 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVerapamil HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxVancomycin 250 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxVancomycin 50 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVancomycin 25 mg/0.1 ml Nasal Solution

Add

Adding

Radio 3

CheckboxVancomycin 2.5% Topical Spray

Add

Adding

Radio 3

CheckboxVancomycin 25 mg/ml Ophthalmic Solution (Fortified)

Add

Adding

Radio 3

CheckboxValproic Acid 125 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxVancomycin 50 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxVancomycin 40 mg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVancomycin 40 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxVancomycin 20 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxValproic Acid 500 mg Suppository

Add

Adding

Radio 3

CheckboxVancomycin 25 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxVancomycin 50 mg/Amphotericin B 10 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxValproic Acid 125 mg Troche

Add

Adding

Radio 3

CheckboxValproic Acid 50 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxUrsodiol 100 mg Capsules

Add

Adding

Radio 3

CheckboxUrsodiol 300 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxValacyclovir 50 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxUrea 20%/Lactic Acid 4.25% Topical Gel

Add

Adding

Radio 3

CheckboxUrea 40%/Salicylic Acid 3% Topical Cream

Add

Adding

Radio 3

CheckboxUrsodiol 20 mg/ml To 100 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxValproate Sodium 250 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxUrea 20%/Salicylic Acid 5%/Ammonium Lactate 4% Topical Cream

Add

Adding

Radio 3

CheckboxUrea 25%/Salicylic Acid 5% Topical Ointment

Add

Adding

Radio 3

CheckboxTris 0.6%/Edetate Disodium 0.12% Buffered Otic Solution (Vet)

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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