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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

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

CheckboxPotassium Bromide 100 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxPodophyllum 20% Topical Ointment

Add

Adding

Radio 3

CheckboxPodophyllum Resin 15%/Salicylic Acid 15%/Acyclovir 5% Topical Solution

Add

Adding

Radio 3

CheckboxPolyethylene Glycol 500 mg Capsules

Add

Adding

Radio 3

CheckboxPodophyllum 25% In Tincture Of Benzoin

Add

Adding

Radio 3

CheckboxPodophyllum 20% Topical Gel

Add

Adding

Radio 3

CheckboxPodophyllum 20%/Benzocaine 4.75% Topical Gel

Add

Adding

Radio 3

CheckboxPodophyllum 10% Topical Gel

Add

Adding

Radio 3

CheckboxPiroxicam 20 mg Suppository

Add

Adding

Radio 3

CheckboxPolymyxin B 6,320 U/ml/Bacitracin 500 U/ml Topical Gel

Add

Adding

Radio 3

CheckboxPodophyllum 10%/Salicylic Acid 10%/Trichloroacetic Acid 10% Topical Solution

Add

Adding

Radio 3

CheckboxPolymyxin B 10,000 U/Gm/Bacitracin 500 U/Gm Topical Ointment

Add

Adding

Radio 3

CheckboxPolymyxin B 10,000 U/ml/Bacitracin 500 U/ml Topical Solution

Add

Adding

Radio 3

CheckboxPolymyxin B 12,500 U/Gm/Bacitracin 500 U/Gm Topical Powder

Add

Adding

Radio 3

CheckboxPodophyllum 10%/Benzocaine 4.75% Topical Gel

Add

Adding

Radio 3

CheckboxPodophyllum 20%/Salicylic Acid 6% In Flexible Collodion

Add

Adding

Radio 3

CheckboxPiroxicam 10 mg Suppository

Add

Adding

Radio 3

CheckboxPolymyxin B 1000 U/ml/Bacitracin 500 U/ml/Neomycin 0.007% Irrigation Solution

Add

Adding

Radio 3

CheckboxPiroxicam 5% Topical Gel

Add

Adding

Radio 3

CheckboxPiroxicam 3.5 mg Capsules

Add

Adding

Radio 3

CheckboxPiroxicam 1 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxPhytonadione 25 mg Capsules

Add

Adding

Radio 3

CheckboxPiroxicam 2% Topical Gel

Add

Adding

Radio 3

CheckboxPiroxicam 2 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxPhytonadione 1%/Vitamin E Acetate 2.5 Iu/Gm/Ascorbic Acid 5% Topical Cream

Add

Adding

Radio 3

CheckboxPhenytoin 50 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxPhytonadione 1%/Retinol 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxPilocarpine HCl 2 mg/ml Oral Drops

Add

Adding

Radio 3

CheckboxPhenytoin 5%/Nifedipine 2%/Misoprostol 0.0024% Topical Gel

Add

Adding

Radio 3

CheckboxPiroxicam 1% Topical Gel

Add

Adding

Radio 3

CheckboxPilocarpine HCl 2 mg Polyglycol Troche

Add

Adding

Radio 3

CheckboxPhytonadione 10 mg Capsules

Add

Adding

Radio 3

CheckboxPhenytoin 10% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 125 mg/5 ml Oral Suspension (Gluten Free/Flavored)

Add

Adding

Radio 3

CheckboxPhytonadione 1 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxPhytonadione 5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxPiroxicam 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxPiroxicam 2 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxPhenytoin 1% To 5% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 5%/Gentamicin 0.2%/Misoprostol 0.0024% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 2%/Arginine HCl 1%/Naltrexone HCl 0.5%/Timolol 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 5%/Metronidazole 2%/Misoprostol 0.0024% Polyox Wound Bandage

Add

Adding

Radio 3

CheckboxPhenytoin 2%/Arginine HCl 1%/Naltrexone HCl 1%/Aloe Vera 0.2%/Misoprostol 0.0024% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 2%/Tetracaine 1%/Aloe Vera 0.2%/Misoprostol 0.0024% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 5%/Clindamycin 2%/Arginine HCl 1%/Naltrexone HCl 0.5%/Aloe Vera 0.2%/Nifedipine 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 5%/Misoprostol 0.0024% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 2%/Arginine HCl 1%/Naltrexone HCl 1%/Misoprostol 0.0024%/Aloe Vera Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 2%/Naltrexone HCl 0.5%/Aloe Vera 0.2% Vaginal Gel

Add

Adding

Radio 3

CheckboxPhenytoin 5%/Misoprostol 0.0024%/Nifedipine 2% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 2%/Arginine HCl 1%/Melatonin 1%/Naltrexone HCl 1%/Aloe Vera Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 2%/Aloe Vera 0.2%/Misoprostol 0.0024% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 5%/Naltrexone HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 5%/Misoprostol 0.0024%/Arginine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxPhenytoin 2%/Misoprostol 0.0024% Vaginal Gel

Add

Adding

Radio 3

CheckboxPhenytoin 5% Topical Gel

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 50 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 0.5%/Pyrilamine Maleate 0.1% Nasal Solution

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 1%/Chlorpheniramine Maleate 0.4%/Atropine Sulfate 0.05% Nasal Spray

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 10%/Pentoxifylline 5% Topical Lipoderm® (Vet)

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 0.5% Nasal Solution

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 20 mg/Guaifenesin 600 mg/Brompheniramine Maleate 8 mg/Dextromethorphan HBr 50 mg Capsules

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 0.25%/Antipyrine 5%/Benzocaine 5% Otic Solution

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 12.5 mg/0.1 ml Oral Solution (Vet-Canine)

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 2.5% Ophthalmic Solution

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 75 mg Slow Release Capsules (Vet)

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 0.17% Nasal Solution

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 20 mg/Guaifenesin 600 mg/Brompheniramine Maleate 8 mg Capsules

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 0.12% Ophthalmic Solution

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 25 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 50 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 1 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxPhenylpropanolamine HCl 2.5 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxPhenylbutazone 200 mg Capsules

Add

Adding

Radio 3

CheckboxPhentermine 30 mg Slow Release CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxPhenoxybenzamine HCl 2 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxPhenoxybenzamine HCl 10 mg Capsules

Add

Adding

Radio 3

CheckboxPhenoxybenzamine HCl 30 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxPhenoxybenzamine HCl 2.5 mg Capsules

Add

Adding

Radio 3

CheckboxPhenol 5.6%

Add

Adding

Radio 3

CheckboxPhentermine 15 mg Slow Release CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxPhenylbutazone 100 mg Capsules

Add

Adding

Radio 3

CheckboxPhentermine 15 mg CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxPhentermine 30 mg CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxPhenylephrine HCl 0.1 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxPhenylbutazone 200 mg/ml Oral Gel (Vet)

Add

Adding

Radio 3

CheckboxPhenol 20% Topical Solution

Add

Adding

Radio 3

CheckboxPhenoxybenzamine HCl 15 mg/Gm Topical Cream

Add

Adding

Radio 3

CheckboxPhenol 1.5% Oral Rinse

Add

Adding

Radio 3

CheckboxPhenoxybenzamine HCl 5 mg Capsules

Add

Adding

Radio 3

CheckboxPhenol 58.4% Topical Suspension

Add

Adding

Radio 3

CheckboxPhenylbutazone 500 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxPhenylbutazone 10% Topical Gel

Add

Adding

Radio 3

CheckboxPhenobarbital 15 mg/5 ml Oral Suspension

Add

Adding

Radio 3

CheckboxPhenobarbital 200 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxPhenobarbital 30 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxPhenobarbital 30 mgÂ Suppository

Add

Adding

Radio 3

CheckboxPhenobarbital 120 mgÂ Suppository

Add

Adding

Radio 3

CheckboxPhenazopyridine HCl 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxPhenobarbital 3 mg/ml/Hyoscyamine Sulfate 0.025 mg/ml Oral Elixir

Add

Adding

Radio 3

CheckboxPhenobarbital 16.2 mg/Hyoscyamine Sulfate 0.1037 mg/Atropine Sulfate 0.0194 mg/Scopolamine HBr 0.0065 mg Capsules

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!

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