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 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

CheckboxPhenol 0.5%/Camphor 0.5%/Menthol 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxPhenol 1.4%/Menthol 0.12% Troche

Add

Adding

Radio 3

CheckboxPhenol 0.6% Mouthwash

Add

Adding

Radio 3

CheckboxPhenobarbital 90 mgÂ Suppository

Add

Adding

Radio 3

CheckboxPhenobarbital 15 mg/ml/Hyoscyamine Sulfate 0.125 mg/ml Oral Drops

Add

Adding

Radio 3

CheckboxPhenobarbital 24 mg/ml/Homatropine Methylbromide 0.27 mg/ml Oral Drops

Add

Adding

Radio 3

CheckboxPhenobarbital 3.24 mg/ml/Belladonna Leaf Alkaloids 0.025 mg/ml Oral Elixir

Add

Adding

Radio 3

CheckboxPhenazopyridine HCl 200 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxPhenobarbital 200 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxPhenazopyridine HCl 100 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxPhenobarbital 60 mgÂ Suppository

Add

Adding

Radio 3

CheckboxPhenobarbital 3.24 mg/ml/Belladonna Leaf Alkaloids 0.025 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxPhenobarbital 10 mg/0.1 ml Topical Cream (Vet)

Add

Adding

Radio 3

CheckboxPhenobarbital 1 mg/ml To 50 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxPhenobarbital 4 mg CapsulesÂ (Vet)

Add

Adding

Radio 3

CheckboxPentoxifylline 10 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxPentoxifylline 15% Topical Gel

Add

Adding

Radio 3

CheckboxPergolide 1 mg/5 ml Oral Suspension (Vet-Equine)

Add

Adding

Radio 3

CheckboxPentoxifylline 45 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxPentoxifylline 100 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxPentoxifylline 400 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxPentoxifylline 5%/Tacrolimus 0.1%/Ketotifen 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxPentoxifylline 90 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxPentoxifylline 10% Topical Gel

Add

Adding

Radio 3

CheckboxPentoxifylline 200 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxPentoxifylline 5%/Rifampin 2%/Clindamycin 1%/Glycolic Acid Topical Cream

Add

Adding

Radio 3

CheckboxPentoxifylline 70 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxPentosan Polysulfate Sodium 15 mg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxPentoxifylline 1% Topical Gel

Add

Adding

Radio 3

CheckboxPentoxifylline 5% To 15% Topical Gel

Add

Adding

Radio 3

CheckboxPentoxifylline 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxPapaverine HCl 20 mg/ml/Phentolamine Mesylate 1 mg/ml/Alprostadil 200 Mcg/ml/Sildenafil 5 mg/ml Urethral Gel

Add

Adding

Radio 3

CheckboxPentoxifylline 0.3%/Caffeine 1%/Egcg 1% Topical Gel

Add

Adding

Radio 3

CheckboxPentoxifylline 2%/Naltrexone HCl 0.2%/Aloe Vera Topical/Vaginal

Add

Adding

Radio 3

CheckboxParomomycin 25 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxParomomycin 250 mg Capsules

Add

Adding

Radio 3

CheckboxPentoxifylline 1%/Ketotifen 0.05%/Caffeine 1% Topical Gel

Add

Adding

Radio 3

CheckboxPentoxifylline 5%/Nifedipine 2% Topical Gel

Add

Adding

Radio 3

CheckboxPentoxifylline 2%/Ketotifen 0.05% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxPentosan Polysulfate Sodium 1 mg/Gm Topical Cream

Add

Adding

Radio 3

CheckboxParomomycin 250 mg Suppository

Add

Adding

Radio 3

CheckboxPentoxifylline 3%/Phenytoin 2%/Misoprostol 0.0024%/Aloe Vera Topical Gel

Add

Adding

Radio 3

CheckboxPapaverine HCl 150 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxPapaverine HCl 300 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxPentosan Polysulfate Sodium 100 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxParomomycin 6.25% Vaginal Ointment

Add

Adding

Radio 3

CheckboxPapaverine HCl 5%/Arginine HCl 6% Topical Cream

Add

Adding

Radio 3

CheckboxPentoxifylline 5%/Montelukast 1% Topical Gel

Add

Adding

Radio 3

CheckboxOxymetazoline HCl 0.06% Topical Gel

Add

Adding

Radio 3

CheckboxOxycodone HCl 20 mgÂ Suppository

Add

Adding

Radio 3

CheckboxOxytocin 40 Units/Gm Vaginal Cream

Add

Adding

Radio 3

CheckboxOxymetazoline HCl 0.05%/Menthol/Camphor Nasal Solution

Add

Adding

Radio 3

CheckboxPapaverine 20% Topical Gel

Add

Adding

Radio 3

CheckboxOxycodone HCl 20 mg/ml Oral SuspensionÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxOxymetazoline HCl 1%/Ketotifen 0.05%/Tea Tree Oil 5% Topical Gel

Add

Adding

Radio 3

CheckboxOxytocin 12 Units/0.1 ml/Hydroxocobalamin 0.5 mg/0.1 ml Nasal Spray

Add

Adding

Radio 3

CheckboxOxytocin 24 Units/0.5 ml Sublingual Suspension

Add

Adding

Radio 3

CheckboxOxycodone HCl 30 mgÂ Suppository

Add

Adding

Radio 3

CheckboxPapaverine HCl 0.1%/Arginine 6% Topical Cream

Add

Adding

Radio 3

CheckboxPantoprazole 2 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxOxymetazoline HCl 0.06% Topical Lotion

Add

Adding

Radio 3

CheckboxOxycodone HCl 30 mg Slow Release CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxOxymetazoline HCl 0.06% Topical Cream

Add

Adding

Radio 3

CheckboxOxytocin 20 Units/Gm Vaginal Gel

Add

Adding

Radio 3

CheckboxPapaverine 15% Topical Gel

Add

Adding

Radio 3

CheckboxOxytocin 20 Units/Gm Topical Cream

Add

Adding

Radio 3

CheckboxOxycodone HCl 40 mg Slow Release CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxOxycodone HCl 20 mg Slow Release CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxOxymetazoline HCl 1%/Ketotifen 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxOxytocin 120 U/Gm Vaginal Gel

Add

Adding

Radio 3

CheckboxOxymetazoline HCl 1 mg/0.2 ml Topical Gel

Add

Adding

Radio 3

CheckboxOxytocin 10 Units/0.1 ml To 100 Units/0.1 ml Nasal Spray

Add

Adding

Radio 3

CheckboxOxybutynin Chloride 8% Topical Gel

Add

Adding

Radio 3

CheckboxOxycodone HCl 15 mgÂ Suppository

Add

Adding

Radio 3

CheckboxOndansetron 8 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxOndansetron 20 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxOndansetron 4 mg/0.1 ml Topical Cream

Add

Adding

Radio 3

CheckboxOxybutynin Chloride 7.5 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxOxycodone HCl 10 mgÂ Suppository

Add

Adding

Radio 3

CheckboxOrphenadrine Citrate 5% Topical Gel

Add

Adding

Radio 3

CheckboxOndansetron 8 mg Suppository

Add

Adding

Radio 3

CheckboxOxycodone HCl 5 mgÂ Troche

Add

Adding

Radio 3

CheckboxOxybutynin Chloride 5 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxOxycodone HCl 5 mgÂ Suppository

Add

Adding

Radio 3

CheckboxOndansetron 4 mg Suppository

Add

Adding

Radio 3

CheckboxOxybutynin Chloride 0.1% Bladder Irrigation Solution

Add

Adding

Radio 3

CheckboxOrphenadrine Citrate 10% Topical Gel

Add

Adding

Radio 3

CheckboxOxybutynin Chloride 1 mg/ml Oral Syrup (Gluten Free/Flavored)

Add

Adding

Radio 3

CheckboxOxycodone HCl 5 mg Slow Release CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxOxycodone HCl 2 mg Capsules

Add

Adding

Radio 3

CheckboxOmeprazole 20 mg Ar Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxOndansetron 4 mg/5 ml Oral Suspension (Gluten Free)

Add

Adding

Radio 3

CheckboxOndansetron 4 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxOrphenadrine Citrate 100 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxOndansetron 20 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxOxycodone HCl 10 mg Slow Release CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxOxybutynin Chloride 10%/Glycopyrrolate 0.25% Topical Gel

Add

Adding

Radio 3

CheckboxNystatin 200,000 Units/Acyclovir 180 mg Popsicle

Add

Adding

Radio 3

CheckboxNystatin 100,000 Units Suppository

Add

Adding

Radio 3

CheckboxNystatin 500,000 Units 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!

Oops! Something went wrong while submitting the form.