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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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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

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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

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Adding

Radio 3

CheckboxTobramycin 125 mg/Mupirocin 5 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 125 mg/Amphotericin B 5 mg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 125 mg/Mupirocin 5 mg/Mometasone Furoate 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 100 mg/Fluticasone Propionate 1 mg Capsules (For Nasal Irrigation/Nebulizer)

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Radio 3

CheckboxTobramycin 125 mg/Itraconazole 40 mg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 125 mg/Mupirocin 5 mg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 20 mg/Mupirocin 15 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 20 mg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 80 mg Capsules (For Nasal Irrigation/Nebulizer)

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Radio 3

CheckboxTobramycin 80 mg/Amphotericin B 10 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

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Radio 3

CheckboxTobramycin 100 mg/Amphotericin B 5 mg/Budesonide 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 100 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 80 mg/Itraconazole 50 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 20 mg/Mupirocin 5 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 100 mg/Amphotericin B 5 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxTobramycin 100 mg/Acetylcysteine 20 mg Capsules (For Nasal Irrigation/Nebulizer)

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Radio 3

CheckboxTobramycin 0.3% Ophthalmic Solution

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Adding

Radio 3

CheckboxThymol 4%/Ibuprofen 2%/Alcohol Topical Nail Solution

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Radio 3

CheckboxTobramycin 20 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxThymol 4%/Alcohol Topical Nail Solution

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Adding

Radio 3

CheckboxTimolol 0.5% Nasal Spray

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Radio 3

CheckboxTobramycin 13.6 mg/ml Ophthalmic Solution (Fortified)

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Radio 3

CheckboxTitanium Dioxide 10%/Zinc Oxide 15% Topical Cream

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Radio 3

CheckboxTitanium Dioxide 1% Topical Lotion

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Radio 3

CheckboxTinidazole 500 mg Suppository

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Radio 3

CheckboxTitanium Dioxide 40% Topical Suspension

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Radio 3

CheckboxTimolol 0.5% Topical Gel

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Radio 3

CheckboxTimolol Maleate 10 mg/Hydrochlorothiazide 25 mg Capsules

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Radio 3

CheckboxThiabendazole 200 mg/ml Oral Gel (Vet)

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Radio 3

CheckboxThiamine HCl 5% Topical Suspension

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Radio 3

CheckboxThioridazine HCl 100 mg/ml Oral Solution

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Radio 3

CheckboxThiamine HCl 1.1 mg/ml/B-12 2.5 Mcg/ml Oral Elixir

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Radio 3

CheckboxThiamine HCl 100 mg Troche

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Radio 3

CheckboxThiamine HCl 25 mg/ml Oral Suspension

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Radio 3

CheckboxThioridazine 20 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxThiamine HCl 10 mg/ml/Ascorbic Acid 50 mg/ml Oral Drops

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Adding

Radio 3

CheckboxThiabendazole 100 mg/ml Oral Suspension (Vet-Canine)

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Adding

Radio 3

CheckboxThiabendazole 10% Topical Cream

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Adding

Radio 3

CheckboxTetracycline HCl 125 mg/5 ml Oral Suspension

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Adding

Radio 3

CheckboxTetracycline HCl 100 mg/ml Oral Suspension (Vet)

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Radio 3

CheckboxThiabendazole 100 mg/ml Oral Suspension

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Radio 3

CheckboxTetracycline HCl 500 mg Capsules (Gluten Free)

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Radio 3

CheckboxTheanine 0.5%/Quercetin Dihydrate 1% Topical Gel (Vet)

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Radio 3

CheckboxThiabendazole 40 mg/ml/Neomycin 3.2 mg/ml/Dexamethasone 1 mg/ml Topical Suspension (Vet)

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Adding

Radio 3

CheckboxTetracycline HCl 125 mg/Diphenhydramine HCl 12.5 mg/Nystatin 60,417 Units/Hydrocortisone 2.3 mg Troche

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Adding

Radio 3

CheckboxTetracycline HCl 250 mg Capsules (Sustained Release)

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Adding

Radio 3

CheckboxTetracycline HCl 125 mg/Nystatin 100,000 Units/Diphenhydramine HCl 12.5 mg/Hydrocortisone 2.5 mg Troche

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Adding

Radio 3

CheckboxTetracycline HCl 250 mg/Nystatin 100,000 Units Suppository

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Adding

Radio 3

CheckboxTetracycline HCl 250 mg/Amphotericin B 50 mg Capsules

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Adding

Radio 3

CheckboxTetracycline HCl 12.5 mg/ml/Nystatin 12,000 Units/ml/Hydrocortisone 0.46 mg/ml/Diphenhydramine HCl Mouthwash

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Adding

Radio 3

CheckboxTetracycline HCl 12.5 mg/ml/Nystatin 12,000 Units/ml/Hydrocortisone 0.5 mg/ml/Chlorpheniramine Maleate 0.2 mg/ml Mouthwash

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Adding

Radio 3

CheckboxTetracycline HCl 2 mg/ml/Nystatin 4,800 Units/ml/Hydrocortisone 0.4 mg/ml/Diphenhydramine HCl Mouthwash

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Adding

Radio 3

CheckboxTetracycline HCl 3% Vaginal Cream

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Adding

Radio 3

CheckboxTetracycline HCl 13.5 mg/ml/Nystatin 16,667 Units/ml/Diphenhydramine HCl 1.25 mg/ml/Dexamethasone 3.3 Mcg/ml Mouthwash

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Adding

Radio 3

CheckboxTetracycline 12.5 mg/ml/Nystatin 16,667 Units/ml/Diphenhydramine 1.25 mg/ml/Dexamethasone 3.3 Mcg/ml Mouthwash

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Adding

Radio 3

CheckboxTetracycline HCl 12 mg/ml/Nystatin 12,000 Units/ml/Triamcinolone Acetonide 1 mg/ml/Chlorpheniramine Maleate 0.2 mg/ml/Deoxy-D-Glucose Mouthwash

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Adding

Radio 3

CheckboxTetracycline HCl 0.22% Topical Solution

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Adding

Radio 3

CheckboxTetracycline HCl 12.5 mg/ml/Nystatin 12,000 Units/ml/Hydrocortisone 0.46 mg/ml/Chlorpheniramine Maleate 0.2 mg/ml Mouthwash

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Adding

Radio 3

CheckboxTetracycline HCl 13.2 mg/ml/Nystatin 12,685 U/ml/Hydrocortisone 2.11 mg/ml/Chlorpheniramine Maleate 0.14 mg/ml Mouthwash

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Adding

Radio 3

CheckboxTetracaine HCl 4%/Lidocaine HCl 2.5%/Diphenhydramine HCl 1%/Betamethasone Valerate 0.15% Topical Gel

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Adding

Radio 3

CheckboxTetracaine HCl 2% Topical Gel

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Adding

Radio 3

CheckboxTetracaine 4% Topical Anesthetic Cream

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Adding

Radio 3

CheckboxTetracaine HCl 1%/Naltrexone HCl 0.5 mg/ml/Clonazepam 0.2 mg/ml Oral Rinse

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Adding

Radio 3

CheckboxTetracaine 4%/Lidocaine 2.5% Topical Cream

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Adding

Radio 3

CheckboxTetracaine 4%/Diclofenac Sodium 3%/Baclofen 2%/Cyclobenzaprine HCl 2% Topical Cream

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Adding

Radio 3

CheckboxTetracaine 30% Otic Solution

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Adding

Radio 3

CheckboxTetracaine HCl 2% Topical Solution

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Adding

Radio 3

CheckboxTetracaine HCl 0.5% Oral Solution

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Adding

Radio 3

CheckboxTetracaine 2.5%/Lidocaine 2.5% Topical Cream

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Adding

Radio 3

CheckboxTetracaine HCl 0.5%/Neomycin 0.35%/Triamcinolone Acetonide 0.1% Topical Powder (Vet)

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Radio 3

CheckboxTetracaine HCl 0.025% Popsicle

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Adding

Radio 3

CheckboxTestosterone 50 mg/ml/Anastrozole 0.5 mg/ml Topical Solution

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Adding

Radio 3

CheckboxTestosterone 50 mg/Gm/Anastrozole 0.5 mg/Gm Topical Cream

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Adding

Radio 3

CheckboxTestosterone 12.5 mg/Anastrozole 0.1 mg Sublingual Tablet

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Radio 3

CheckboxTestosterone 50 mg Oral Dissolve Tablet

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Adding

Radio 3

CheckboxTestosterone 50 mg/Gm/Anastrozole 0.5 mg/Gm Topical Gel

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Adding

Radio 3

CheckboxTestosterone 25 mg/0.2 ml/Anastrozole 0.1 mg/0.5 ml Sublingual Suspension

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Adding

Radio 3

CheckboxTestosterone 25 mgÂ Troche

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Adding

Radio 3

CheckboxTestosterone 100 mg Rapid Dissolve Tablet

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Adding

Radio 3

CheckboxTestosterone 25 mg/0.2 ml/Anastrozole 0.1 mg/0.5 ml Sublingual Drops

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Adding

Radio 3

CheckboxTestosterone 20 mg/Gm Topical Gel

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Adding

Radio 3

CheckboxTetracaine 1%/Triamcinolone 0.1%/Misoprostol 0.0024% Oral Polyox Bandage

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Adding

Radio 3

CheckboxTestosterone 5 mg/ml Sublingual Solution

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Adding

Radio 3

CheckboxTestosterone 5 mg Troche

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Adding

Radio 3

CheckboxTestosterone 10 mgÂ Troche

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Adding

Radio 3

CheckboxTestosterone 5% Topical Gel

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Radio 3

CheckboxTestosterone 10 mg Troche

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Adding

Radio 3

CheckboxTestosterone 10%/Progesterone 1% Topical Gel

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Adding

Radio 3

CheckboxTestosterone 5% Scalp Lotion

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Adding

Radio 3

CheckboxTestosterone 5%/Progesterone 1% Topical Gel

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Adding

Radio 3

CheckboxTestosterone 10 mg/0.5 ml Sublingual Suspension

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Radio 3

CheckboxTestosterone 2 mg Troche

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Adding

Radio 3

CheckboxTestosterone 5 mgÂ Troche

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Adding

Radio 3

CheckboxTestosterone 1 mg/Gm Topical Gel

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Adding

Radio 3

CheckboxTestosterone 5 mg Rapid Dissolve Tablet

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Radio 3

CheckboxTestosterone 1.5%/Anastrozole 0.04% Topical Gel

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Radio 3

CheckboxTestosterone 2.5% Scalp Lotion

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Adding

Radio 3

CheckboxTestosterone 1% Topical Gel

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Adding

Radio 3

CheckboxTestosterone 2 mg Slow Release Capsules

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Adding

Radio 3

CheckboxTestosterone 1 mg Slow Release Capsules

Directions:

QTY:

Refills

1

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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