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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

CheckboxTestosterone 1 mg/0.1 ml/Estriol/Estradiol [50%/50%] 0.25 mg/0.1 ml Sublingual Suspension

Add

Adding

Radio 3

CheckboxTestosterone 0.5 to 2 mg/ml Vaginal Gel

Add

Adding

Radio 3

CheckboxTestosterone 1 mg Troche

Add

Adding

Radio 3

CheckboxTestosterone 0.5 mg/Gm/Metformin HCl 100 mg/Gm Topical Cream

Add

Adding

Radio 3

CheckboxTerbutaline Sulfate 5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxTestosterone 0.1% To 20% Topical Cream

Add

Adding

Radio 3

CheckboxTestosterone 0.25 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxTestosterone 1 mg/Gm To 10 mg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxTestosterone 0.75 mg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxTerbinafine HCl 1% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxTerbutaline Sulfate 1 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxTerbutaline Sulfate 2.5 mg Troche

Add

Adding

Radio 3

CheckboxTerbinafine HCl 3%/Itraconazole 1%/DMSO/Urea/Tea Tree Oil/Biotin Nail Suspension

Add

Adding

Radio 3

CheckboxTerbutaline Sulfate 2.5 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxTerbutaline Sulfate 2.5 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxTerbinafine HCl 1%/Acetic Acid 2%/Hydrocortisone 1% Otic Solution (Vet)

Add

Adding

Radio 3

CheckboxTerbinafine HCl 1% Vaginal

Add

Adding

Radio 3

CheckboxTamoxifen Citrate 0.1%/Ketotifen 0.05%/Betamethasone Valerate 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxTamoxifen Citrate 0.1%/Azelastine HCl 0.1%/Caffeine 1%/Lipoic Acid 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxTea Tree Oil 5% Topical Shampoo

Add

Adding

Radio 3

CheckboxTaurine 5% Topical Cream

Add

Adding

Radio 3

CheckboxTerbinafine HCl 1.67% Topical Solution

Add

Adding

Radio 3

CheckboxTamoxifen Citrate 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxTerbinafine 25 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxTea Tree Oil 16 mg Suppository

Add

Adding

Radio 3

CheckboxTadalafil 10 mg/Sildenafil 25 mg Troche

Add

Adding

Radio 3

CheckboxTamoxifen 2.5 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxTadalafil 3 mg/Gm/Sildenafil 2 mg/Gm Vaginal Gel

Add

Adding

Radio 3

CheckboxTadalafil 2% Topical Gel

Add

Adding

Radio 3

CheckboxTadalafil 20 mg/Oxytocin 10 Units Sublingual Tablet

Add

Adding

Radio 3

CheckboxTadalafil 5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxTadalafil 20 mg/Pyridoxal-5-Phosphate 50 mg Troche

Add

Adding

Radio 3

CheckboxTadalafil 10 mg/Apomorphine HCl 2 mg Troche

Add

Adding

Radio 3

CheckboxDesiccated Thyroid 15mg to 325 mg Capsules

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Adding

Radio 3

CheckboxTacrolimus 0.2% Otic Solution

Add

Adding

Radio 3

CheckboxTacrolimus 0.5 mg/ml To 1 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxTacrolimus 1 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxTacrolimus 0.125% Oil Ophthalmic Solution

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Adding

Radio 3

CheckboxTadalafil 2 mg Troche

Add

Adding

Radio 3

CheckboxTacrolimus 0.03% Oral Rinse

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Adding

Radio 3

CheckboxTacrolimus 2 mg Suppository

Add

Adding

Radio 3

CheckboxTacrolimus 0.5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxTacrolimus 0.03% Oil Ophthalmic Solution

Add

Adding

Radio 3

CheckboxTadalafil 1 mg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxTacrolimus 0.03% Vaginal Gel

Add

Adding

Radio 3

CheckboxTacrolimus 4 mg/60 ml Rectal Enema

Add

Adding

Radio 3

CheckboxTadalafil 1 mg/Gm/Lidocaine 10 mg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxTadalafil 2.5 mg/0.1 ml Nasal Spray

Add

Adding

Radio 3

CheckboxTacrolimus 0.03%/Azelastine HCl 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxTacrolimus 0.1% Topical Ointment

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Adding

Radio 3

CheckboxTacrolimus 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxSulfur 2%/Salicylic Acid 2% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxSulfur 5%/Salicylic Acid 2% Topical Suspension

Add

Adding

Radio 3

CheckboxTacrolimus 0.1% Scalp Solution

Add

Adding

Radio 3

CheckboxTacrolimus 0.1% Rectal Gel

Add

Adding

Radio 3

CheckboxSulfur 5%/Camphor 0.25%/Calamine 4% Topical Cream

Add

Adding

Radio 3

CheckboxTacrolimus 0.1% Nasal Spray

Add

Adding

Radio 3

CheckboxSulfur 2% Topical Gel

Add

Adding

Radio 3

CheckboxTacrolimus 0.1%/DMSO Nail Gel

Add

Adding

Radio 3

CheckboxTacrolimus 0.1%/Ketotifen 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxSulfur 2%/Salicylic Acid 1.5% Topical Cleanser Lotion

Add

Adding

Radio 3

CheckboxSulfur 4% Topical Gel

Add

Adding

Radio 3

CheckboxSulfur 3%/Salicylic Acid 2%/Hydrocortisone 1% Topical Cream

Add

Adding

Radio 3

CheckboxSulfur 5%/Salicylic Acid 2% Topical Ointment

Add

Adding

Radio 3

CheckboxSulfasalazine 50 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxSulfasalazine 100 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxSulfasalazine 250 mg Capsules

Add

Adding

Radio 3

CheckboxSulfasalazine 500 mg Suppository

Add

Adding

Radio 3

CheckboxSulfamethoxazole 200 mg/Trimethoprim 80 mg Troche

Add

Adding

Radio 3

CheckboxSulfamethoxazole 200 mg/Trimethoprim 40 mg Suppository

Add

Adding

Radio 3

CheckboxSulfamethoxazole 500 mg/Phenazopyridine HCl 100 mg Capsules

Add

Adding

Radio 3

CheckboxSulfamethoxazole 80 mg/Trimethoprim 50 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxSulfasalazine 250 mg Suppository

Add

Adding

Radio 3

CheckboxSulfasalazine 50 mg/ml Enema

Add

Adding

Radio 3

CheckboxSulfamethoxazole 167 mg/Gm/Trimethoprim 33 mg/Gm Oral Paste (Vet)

Add

Adding

Radio 3

CheckboxSulfur 2% Shampoo

Add

Adding

Radio 3

CheckboxSulfamethoxazole 250 mg/Tetracycline HCl 125 mg/Phenazopyridine HCl 50 mg Capsules

Add

Adding

Radio 3

CheckboxSulfamethoxazole 100 mg Capsules

Add

Adding

Radio 3

CheckboxSulfamethoxazole 200 mg/Trimethoprim 40 mg Troche

Add

Adding

Radio 3

CheckboxSulfacetamide Sodium 1%/Salicylic Acid 1%/Aloe Vera 1% Topical Cream

Add

Adding

Radio 3

CheckboxSulfamethoxazole 0.18%/Trimethoprim 0.113% Nasal Spray

Add

Adding

Radio 3

CheckboxSulfacetamide 5%/Sulfur 3%/Salicylic Acid 1% Topical Gel

Add

Adding

Radio 3

CheckboxSulfacetamide Sodium 10%/Sulfur 5% Topical Gel

Add

Adding

Radio 3

CheckboxSulfamethoxazole 40 mg/ml/Trimethoprim 8 mg/ml Oral Suspension (Gluten Free)

Add

Adding

Radio 3

CheckboxSulfacetamide Sodium 15%/Triamcinolone 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxSulfamethoxazole 80 mg/Trimethoprim 50 mg/Fluconazole 15 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxSulfamethoxazole 50 mg/ml/Trimethoprim 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxSulfacetamide Sodium 15%/Sulfur 5% Topical Cream

Add

Adding

Radio 3

CheckboxSulfacetamide Sodium 5%/Clindamycin 1%/Tretinoin 0.02% Topical Cream

Add

Adding

Radio 3

CheckboxSulfacetamide Sodium 10%/Sulfur 5%/Niacinamide 4% Topical Cream

Add

Adding

Radio 3

CheckboxSucralfate 40 mg/ml Rectal Enema

Add

Adding

Radio 3

CheckboxSulfacetamide Sodium 10%/Sulfur 5% Topical Cream

Add

Adding

Radio 3

CheckboxSulfacetamide Sodium 10%/Sulfur 5% Topical Lotion

Add

Adding

Radio 3

CheckboxSulfacetamide Sodium 10% Topical Lotion

Add

Adding

Radio 3

CheckboxSpironolactone 5%/Niacinamide 2.5%/Clindamycin 1% Topical Gel

Add

Adding

Radio 3

CheckboxSpironolactone 3% Topical Lotion

Add

Adding

Radio 3

CheckboxSucralfate 5%/Lidocaine HCl 0.6%/Nystatin 30,000 Units/ml/Diphenhydramine HCl 0.05%/Hydrocortisone 0.05% Compound Oral Suspension

Add

Adding

Radio 3

CheckboxSquaric Acid Dibutyl Ester 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxStanford Modified Oral Rinse (Lidocaine HCl 5 mg/ml/Nystatin 25,000 units/ml/Diphenhydramine HCl 0.625 mg/ml)

Add

Adding

Radio 3

CheckboxSpironolactone 1%/Finasteride 0.1% Topical Lotion

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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