Order Form Builder | Technician Dashboard | Bayview Pharmacy | Your Compounding Pharmacy of Choice

Home

Prescribe

Your Order Form

Compound Catalog Popular Order Forms

Staff

Compound Catalog

Order Form w/ Formulas

Custom Order Form Popular Order Forms Send Order Forms Documents Hospice Peptides Assessments

Prescribers

Tutorials

Settings

My Account Support Log Out

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.

Need help?

Visit the Tutorials tab to learn more.

First

Last

Optimized for desktop use.
Please view on a larger screen to use this tool.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

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

CheckboxHydrocortisone 2 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxHydrocortisone 150 mg/Lidocaine 180 mg Rectal Rockets

Add

Adding

Radio 3

CheckboxHydrocortisone 100 mg Suppositories

Add

Adding

Radio 3

CheckboxHydrocortisone 10% Ultrasound Gel

Add

Adding

Radio 3

CheckboxHydrocortisone 10% Topical Gel

Add

Adding

Radio 3

CheckboxHydrocortisone 10% Topical Cream

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Resorcinol 2%/Salicylic Acid 2%/Precipitated Sulfur 2% Topical Cream

Add

Adding

Radio 3

CheckboxHydrocortisone 1 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxHydrocodone Bitartrate 5 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxHydrocodone Bitartrate 10 mg Capsules

Add

Adding

Radio 3

CheckboxHydralazine HCl 1 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxHyaluronic Acid 0.6%/Sucralfate 25% Topical Ointment

Add

Adding

Radio 3

CheckboxHaloperidol 0.5 mg/Hydroxyzine HCl 25 mg/Lorazepam 0.5 mg/Metoclopramide HCl 10 mg Suppositories

Add

Adding

Radio 3

CheckboxHaloperidol 1 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxHaloperidol 1 mg/mL Topical Cream

Add

Adding

Radio 3

CheckboxHaloperidol 0.5 mg Suppositories

Add

Adding

Radio 3

CheckboxGuanfacine 0.1 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxGreen Tea Powder Extract 15% Vaginal Cream

Add

Adding

Radio 3

CheckboxGreen Tea 50 mg/g Topical Ointment

Add

Adding

Radio 3

CheckboxGreen Tea 100 mg/g Topical Ointment

Add

Adding

Radio 3

CheckboxGranisetron HCl 0.2 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxGlycolic Acid 8%/Lactic Acid 1%/Salicyclic Acid 2% Topical Lotion

Add

Adding

Radio 3

CheckboxGlycolic Acid 5%/Hydroquinone 1%/Tretinoin 0.025% Topical Cream

Add

Adding

Radio 3

CheckboxGranisetron HCl 0.05 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxGlycolic Acid 3% Topical Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 10%/Lactic Acid 10%/Urea 10% Topical Cream

Add

Adding

Radio 3

CheckboxGlycolic Acid 15% Topical Gel

Add

Adding

Radio 3

CheckboxGlutamine 250 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxGlutathione 250 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxGentamicin Sulfate 2 mg/mL/Misoprostol 0.024 mg/mL/Phenytoin 50 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxGentamicin 26.7 mg/mL Otic Irrigation Solution

Add

Adding

Radio 3

CheckboxGentamicin 2 mg/mL/Misoprostol 24 µg/mL/Phenytoin 50 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxGentamicin 10 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxGabapentin 6%/Ketoprofen 20%/Lidocaine 10% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 6%/Ketamine 10%/Nifedipine 2% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 6%/Ketamine 10% Ketoprofen 10%/Lidocaine 4% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 50 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 50 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxGabapentin 40 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 40 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketamine 10%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 10%/Ketamine 10% Ketoprofen 10%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxFurosemide 40 mg Suppositories

Add

Adding

Radio 3

CheckboxFurosemide 40 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxFluticasone Proprionate 1% Topical Cream

Add

Adding

Radio 3

CheckboxFlurbiprofen 20 mg/g/Silver Sulfadiazine 10 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxFlurbiprofen 100 mg/g/Lidocaine 50 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxFluoxymesterone 10 mg Capsules

Add

Adding

Radio 3

CheckboxFluoxetine HCl 7.5 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxFluoxetine HCl 1 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxFluorouracil 5%/Glycolic Acid 70% Topical Solution

Add

Adding

Radio 3

CheckboxFluocinonide 0.1% Ultrasound Gel

Add

Adding

Radio 3

CheckboxFludrocortisone Acetate 0.02 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxFluconazole 200 mg Suppositories

Add

Adding

Radio 3

CheckboxFluconazole 2%/Tea Tree Oil 5% Topical Solution

Add

Adding

Radio 3

CheckboxFluconazole 2% Shampoo

Add

Adding

Radio 3

CheckboxFluconazole 100 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxFluconazole 1 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxFinasteride 2%/Minoxidil 5% Topical Foam

Add

Adding

Radio 3

CheckboxFentanyl Citrate 25 µg/0.1 mL Nasal Spray

Add

Adding

Radio 3

CheckboxFentanyl 0.2 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxEtodolac 200 mg Suppositories

Add

Adding

Radio 3

CheckboxEthambutol HCl 400 mg Suppositories

Add

Adding

Radio 3

CheckboxDoxepin HCl 5 mg/mL Oral Rinse

Add

Adding

Radio 3

CheckboxEthacrynic Acid 2.5 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxErythromycin Ethylsuccinate 400 mg/mL/Rifampin 50 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxErythromycin Base 250 mg Suppositories

Add

Adding

Radio 3

CheckboxErythromycin 10 mg/g/Neomycin Sulfate 3.5 mg/g Topical Ointment

Add

Adding

Radio 3

CheckboxErlotinib 10 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 2 mg/Caffeine 100 mg/Metoclopramide HCl 10 mg Suppositories

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 2 mg/Caffeine 10 mg/Promethazine HCl 12.5 mg Suppositories

Add

Adding

Radio 3

CheckboxErgoloid Mesylates 15 mg/mL/Selegiline HCl 6.25 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxErgoloid Mesylates 1 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxEnrofloxacin 5 mg/0.5 mL Oral Syrup

Add

Adding

Radio 3

CheckboxEnrofloxacin 0.5%/Ketoconazole 0.1%/Triamcinolone Acetonide 0.1% Otic Gel

Add

Adding

Radio 3

CheckboxEnrofloxacin 0.25% Otic Solution

Add

Adding

Radio 3

CheckboxEnrofloxacin 0.2 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxEnalapril Maleate 1.25 µg/0.1 mL Topical Gel

Add

Adding

Radio 3

CheckboxEnalapril Maleate 2mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxEfavirenz 20 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxEdetate Disodium 1.7% Ophthalmic Solution

Add

Adding

Radio 3

CheckboxEdetate Disodium 0.37% Ophthalmic Solution

Add

Adding

Radio 3

CheckboxDoxycycline Hyclate 10 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxDoxepin HCl 6% Topical Cream

Add

Adding

Radio 3

CheckboxDisulfiram 25 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxDisopyramide 10 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxDisopyramide 1 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 25 mg/Haloperidol 5 mg/Lorazepam 2 mg Suppositories

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 25 mg/Haloperidol 4 mg/Lorazepam 1 mg Troches

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 25 mg/Haloperidol 1.5 mg/Lorazepam 0.34 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 20 mg/mL/Hydrocortisone 5 mg/mL/Lidocaine HCl 20 mg/mL Topical Solution

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 20 mg/mL/Hydrocortisone 5 mg/mL/Lidocaine HCl 20 mg/mL Topical Lotion

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 20 mg/mL/Fluocinonide 3 mg/mL/Pramoxine HCl 10 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 20 mg/g/Hydrocortisone 10 mg/g/Lidocaine HCl 20 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 12.5 mg/Hydrocortisone 2 mg/Nystatin 11.3 mg/Tetracycline 125 mg Troches

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 10 mg/mL/Hydrocortisone Acetate 10 mg/mL/Pramoxine HCl 10 mg/mL Topical Spray

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 1.25%/Haloperidol 0.2%/Lorazepam 0.1%/Metoclopramide 2% Topical Gel

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 1.25 mg/mL/Hydrocortisone 0.5 mg/mL/Nystatin 20000 Units/mL/Tetracycline 12.5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 1.25 mg/mL/Hydrocortisone 0.05 mg/mL/Nystatin 20000 Units/mL/Tetracycline 12.5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 1 mg/mL/Lidocaine HCl 10 mg/mL/Misoprostol 0.24 mg/mL Oral Suspension

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!

Oops! Something went wrong while submitting the form.