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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

CheckboxNystatin 12,500 Units/ml/Diphenhydramine HCl 2.5 mg/ml/Hydrocortisone 0.25 mg/ml Mouthwash

Add

Adding

Radio 3

CheckboxNystatin 100,000 Units/ml Oral Suspension (Sugar Free)

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Adding

Radio 3

CheckboxNortriptyline 100 mg Capsules

Add

Adding

Radio 3

CheckboxNystatin 200,000 Units Troche

Add

Adding

Radio 3

CheckboxNystatin 100,000 Units/Gm/Metronidazole 1% Vaginal Gel

Add

Adding

Radio 3

CheckboxNystatin 100,000 Units/Gm/Nitrofurazone 0.25%/Triamcinolone Acetonide 0.1% Topical Ointment

Add

Adding

Radio 3

CheckboxNystatin 100,000 Units/Gm/Triamcinolone Acetonide 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxNystatin 50,000 Units/ml Nasal Spray

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Adding

Radio 3

CheckboxNystatin 200,000 Units/Gm/Diphenhydramine HCl 2%/Dyclonine HCl 0.1%/Betamethasone 0.05% Topical Cream

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Adding

Radio 3

CheckboxNystatin 100,000 Units/Gm Vaginal Gel

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Adding

Radio 3

CheckboxNystatin 100,000 Units/Gm Topical Gel

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Adding

Radio 3

CheckboxNystatin 200,000 Units/Gm/Diphenhydramine HCl 2%/Mupirocin 0.5%/Betamethasone 0.05% Topical Cream

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Adding

Radio 3

CheckboxOmeprazole 2 mg/ml To 10 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxOmeprazole 20 mg Suppository

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Adding

Radio 3

CheckboxNortriptyline 50 mg/5 ml Oral Syrup

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Adding

Radio 3

CheckboxNystatin 100,000 Units/ml/Neomycin 0.35%/Polymyxin B 10,000 Units/ml/Triamcinolone 0.1% Otic Suspension

Add

Adding

Radio 3

CheckboxNystatin 100,000 Units/Gm/Hydrocortisone Acetate 1% Topical Cream

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Adding

Radio 3

CheckboxNystatin 500,000 Units/ml Topical Gel (Vet)

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Adding

Radio 3

CheckboxNystatin 100,000 Units/Gm/Lidocaine HCl 1%/Ketotifen 0.05% Topical/Vaginal Gel

Add

Adding

Radio 3

CheckboxNystatin 100,000 Units Troche

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Adding

Radio 3

CheckboxNitroglycerin 0.2%/Phenytoin 0.2%/Misoprostol 0.002% Topical Ointment

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Adding

Radio 3

CheckboxNifedipine 3%/Pentoxifylline 3% Topical Cream

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Adding

Radio 3

CheckboxNifedipine 40 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxNitrofurazone 0.2% Topical Cream

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Adding

Radio 3

CheckboxNifedipine 20 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxNitrofurazone 0.2% Topical Solution

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Adding

Radio 3

CheckboxNifedipine 10 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxNifedipine 16% Topical Cream

Add

Adding

Radio 3

CheckboxNitrofurazone 6 mg Vaginal Suppository

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Adding

Radio 3

CheckboxNifedipine 4% Topical Cream

Add

Adding

Radio 3

CheckboxNifedipine 4 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxNitrofurazone 4.2 mg Vaginal Suppository

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Adding

Radio 3

CheckboxNifedipine 10 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxNifedipine 160 mg/ml Topical Gel

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Adding

Radio 3

CheckboxNortriptyline 25 mg/5 ml Oral Syrup

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Adding

Radio 3

CheckboxNitrofurazone 0.02%/Phenylephrine HCl 0.25% Nasal Solution

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Adding

Radio 3

CheckboxNifedipine 80 mg/ml Topical Gel

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Adding

Radio 3

CheckboxNitrofurantoin 10 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxNitrofurazone 0.2% Topical Ointment

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Adding

Radio 3

CheckboxNitroglycerin 0.2% Topical Ointment

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Adding

Radio 3

CheckboxNiacinamide 5%/Biotin 0.1%/Potassium Azeloyl Diglycinate 6% Topical Cream

Add

Adding

Radio 3

CheckboxNicotinamide Adenine Dinucleotide Na2 Reduced 10 mg Slow Release Ar Capsules

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Adding

Radio 3

CheckboxNiacinamide 4%/Tretinoin 0.05%/Clobetasol Propionate 0.025% Topical Cream

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Adding

Radio 3

CheckboxNifedipine 0.2% Suppository

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Adding

Radio 3

CheckboxNiacinamide 4%/Tretinoin 0.05%/Glycolic Acid 2.5% Topical Gel

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Adding

Radio 3

CheckboxNiacinamide 4%/Salicylic Acid 3%/Terbinafine HCl 1% Topical Gel

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Adding

Radio 3

CheckboxNiacinamide 5%/Ivermectin 1%/Potassium Azeloyl Diglycinate 15% Topical Cream

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Adding

Radio 3

CheckboxNiacinamide 4%/Ivermectin 1% Topical Cream

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Adding

Radio 3

CheckboxNifedipine 1 mg/0.25 ml Sublingual Liquid

Add

Adding

Radio 3

CheckboxNiacinamide 25 mg/Iodine 103 mg Capsules

Add

Adding

Radio 3

CheckboxNicotinamide Adenine Dinucleotide Na2 Reduced 5 mg Slow Release Ar Capsules

Add

Adding

Radio 3

CheckboxNiacinamide 4%/Metronidazole 1% Topical Cream

Add

Adding

Radio 3

CheckboxNiacinamide 5%/Kojic Acid 4% Topical Cream

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Adding

Radio 3

CheckboxNiacinamide 250 mg/Acetylcysteine 100 mg Capsules

Add

Adding

Radio 3

CheckboxNiacinamide 5%/Biotin 0.1%/Potassium Azeloyl Diglycinate 6% Topical Gel

Add

Adding

Radio 3

CheckboxNiacinamide 5%/Potassium Azeloyl Diglycinate 15% Topical Cream

Add

Adding

Radio 3

CheckboxNifedipine 2 mg/0.25 ml Sublingual Liquid

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Adding

Radio 3

CheckboxNifedipine 0.2% Rectal Ointment

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Adding

Radio 3

CheckboxNiacinamide 5%/Lipoic Acid 1%/Biotin 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxNiacinamide 4%/Clindamycin 1%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxNeomycin 3.5 mg/Gm/Polymyxin B 5000 U/Gm/Bacitracin 400 U/Gm Topical Powder

Add

Adding

Radio 3

CheckboxNiacinamide 4%/Ivermectin 1%/Metronidazole 0.75% Topical Gel

Add

Adding

Radio 3

CheckboxNeomycin 3.5 mg/Gm/Polymyxin B 5000 U/Gm/Bacitracin 500 U/Gm Topical Ointment

Add

Adding

Radio 3

CheckboxNiacinamide 4%/Biotin 0.1%/Lipoic Acid 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxNeomycin 49 mg/Methscopolamine Bromide 1 mg Capsules (Vet)

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Adding

Radio 3

CheckboxNiacinamide 2%/Minoxidil 1%/Hyaluronic Acid Scalp Solution

Add

Adding

Radio 3

CheckboxNiacinamide 2%/Tranexamic Acid 2% Topical Cream

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Adding

Radio 3

CheckboxNiacinamide 4% Topical Gel

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Adding

Radio 3

CheckboxNeomycin 17.5 mg/ml Oral Solution

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Adding

Radio 3

CheckboxNiacin 50 mg/Meclizine HCl 12.5 mg Capsules

Add

Adding

Radio 3

CheckboxNeomycin 35 mg/ml/Methscopolamine Bromide 0.25 mg/ml Oral Drops (Vet)

Add

Adding

Radio 3

CheckboxNiacin 250 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxNeomycin 35 mg/ml Oral Drops (Vet)

Add

Adding

Radio 3

CheckboxNeomycin 35 mg/Methscopolamine Bromide 0.5 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxNiacinamide 2%/Clindamycin 1% Topical Foam

Add

Adding

Radio 3

CheckboxNiacinamide 3%/Lipoic Acid 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxNiacinamide 4% Topical Cream

Add

Adding

Radio 3

CheckboxNiacin 50 mg/Meclizine HCl 25 mg Capsules

Add

Adding

Radio 3

CheckboxNeomycin 0.35% Rectal Enema

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Adding

Radio 3

CheckboxNaproxen 375 mg/5 ml Oral Suspension

Add

Adding

Radio 3

CheckboxNaproxen 125 mg/5 ml Oral Suspension

Add

Adding

Radio 3

CheckboxNaproxen 375 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxNaproxen 500 mg Suppository

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Adding

Radio 3

CheckboxNaproxen 500 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxNaproxen Sodium 550 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxNeomycin 3.5 mg/Gm/Polymyxin B 10,000 U/Gm/Gramicidin 0.25 mg/Gm Topical Cream

Add

Adding

Radio 3

CheckboxNaproxen 250 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxNaproxen Sodium 275 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxNeomycin 3.5 mg/Gm Topical Ointment

Add

Adding

Radio 3

CheckboxNeomycin 0.35%/Methylprednisolone Acetate 0.25% Topical Ointment

Add

Adding

Radio 3

CheckboxNaproxen 375 mg Suppository

Add

Adding

Radio 3

CheckboxNaproxen 250 mg Suppository

Add

Adding

Radio 3

CheckboxNaproxen 15% Topical Gel

Add

Adding

Radio 3

CheckboxNeomycin 0.35 mg/ml/Gentamicin 0.08 mg/ml/Polymyxin B 100 U/ml Bladder Irrigation

Add

Adding

Radio 3

CheckboxNaproxen Sodium 220 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxNaproxen 250 mg/5 ml Oral Suspension

Add

Adding

Radio 3

CheckboxNeomycin 0.35%/Dexamethasone 0.06% Topical Ointment

Add

Adding

Radio 3

CheckboxNaproxen 5% Topical Gel

Add

Adding

Radio 3

CheckboxNaltrexone HCl 1%/Ketotifen 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxNaproxen 10% Topical Gel

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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