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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

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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

CheckboxMorphine Sulfate 2%/Doxepin HCl 0.5% Oral Rinse

Add

Adding

Radio 3

CheckboxMorphine Sulfate 5% Topical Gel

Add

Adding

Radio 3

CheckboxMorphine Sulfate 1 mg/ml Oral SuspensionÂ (Gluten Free)

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Adding

Radio 3

CheckboxMorphine Sulfate 10 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxMorphine Sulfate 50 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxMorphine Sulfate 25 mgÂ Suppository

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Adding

Radio 3

CheckboxMorphine Sulfate 1 mg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxMorphine Sulfate 30 mg Slow Release Capsules (Gluten Free)

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Adding

Radio 3

CheckboxMorphine Sulfate 20 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMorphine Sulfate 10 mgÂ Troche

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Adding

Radio 3

CheckboxMorphine Sulfate 2% Oral Rinse

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Adding

Radio 3

CheckboxMorphine Sulfate 50 mgÂ Slow Release Suppository

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Adding

Radio 3

CheckboxMorphine Sulfate 1 mg/ml Oral Gel

Add

Adding

Radio 3

CheckboxMorphine Sulfate 60 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxMorphine Sulfate 40 mg/ml Oral Syrup

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Adding

Radio 3

CheckboxMontelukast 1 mg/ml/Ketotifen 0.5 mg/ml/Budesonide 0.5 mg/ml/Quercetin Dihydrate 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Lidocaine HCl 1% Oral Suspension

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Metronidazole 2%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxMontelukast 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxMontelukast 1%/Naltrexone HCl 0.5%/Zinc Pyrithione 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Ciprofloxacin HCl 2% Topical Cream

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Lidocaine HCl 2% Topical Lotion

Add

Adding

Radio 3

CheckboxMontelukast 3 mg/Loratadine 2 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxMontelukast 1%/Loratadine 2% Topical Gel

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Metronidazole 2%/Lidocaine HCl 2% Topical Cream

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Diphenhydramine HCl 0.1%/Lidocaine HCl 1% Oral Rinse

Add

Adding

Radio 3

CheckboxMontelukast 1 mg/ml/Ketotifen 0.5 mg/ml/Budesonide 0.5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxMometasone Furoate 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Ciprofloxacin HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxMontelukast 1%/Naltrexone HCl 0.5%/Ketotifen 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Metronidazole 2% Topical Cream

Add

Adding

Radio 3

CheckboxMometasone Furoate 0.1%/Ketotifen 0.05% Topical Shampoo

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024% Topical Gel

Add

Adding

Radio 3

CheckboxMontelukast 1%/Ketotifen 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxMometasone Furoate 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Phenytoin 5%/Metronidazole 2% Topical Gel

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024% Oral Rinse

Add

Adding

Radio 3

CheckboxMontelukast 3 mg/Loratadine 2 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxMisoprostol 400 Mcg/Gm Vaginal Gel

Add

Adding

Radio 3

CheckboxMinoxidil 10% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Biotin 0.2% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 15% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 7%/Azelaic Acid 5%/Hydrocortisone 1%/Pyridoxine HCl 1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Progesterone 0.5%/Vitamin E Acetate 10 U/ml Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 8.5%/Finasteride 0.1% Scalp Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Zinc Pyrithione 1% Topical Suspension

Add

Adding

Radio 3

CheckboxMinoxidil 7.5%/Naltrexone HCl 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Finasteride 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 15%/Azelaic Acid 2%/Ketoconazole 2%/Biotin 0.25%/Finasteride 0.25%/Tea Tree Oil 0.25%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10% Topical Shampoo

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Progesterone 0.25%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 12.5%/Azelaic Acid 5%/Tretinoin 0.025% Topical Cream

Add

Adding

Radio 3

CheckboxMinoxidil 8.5%/Finasteride 0.1% Topical Shampoo

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Finasteride 0.1% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Azelaic Acid 5% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Finasteride 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Biotin 0.2%/Finasteride 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Finasteride 0.1%/Tretinoin 0.025%/Fluocinolone Acetonide 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 12.5% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 6%/Estriol 0.1%/Zinc Acetate 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Melatonin 0.1%/Finasteride 0.1%/Tretinoin 0.05% Scalp Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Clobetasol Propionate 0.05% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Estradiol 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.01% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.25%/Coenzyme Q-10 0.1%/Melatonin 0.1%/Cyanocobalamin 0.07% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.5%/Vitamin E Acetate 10 IU/ml Scalp Solution

Add

Adding

Radio 3

CheckboxMinoxidil 7.5%/Estradiol 0.025%/Finasteride 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tea Tree Oil 1%/Niacinamide 0.5%/Finasteride 0.016%/Tretinoin 0.01% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Dutasteride 0.05%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.25%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tacrolimus 0.3%/Clobetasol Propionate 0.05% Topical Foam

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Finasteride 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.01%/Betamethasone Valerate 0.05%/Melatonin 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Finasteride 0.25%/Vitamin E Acetate 0.1%/Fluocinolone Acetonide 0.01%/Tretinoin 0.01% Scalp Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Azelaic Acid 1.5%/Dutasteride 0.05% Topical Foam

Add

Adding

Radio 3

CheckboxMinoxidil 6%/Finasteride 0.1%/Tretinoin 0.0125%/Triamcinolone 0.0125%/Dutasteride 0.005% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.025%/Finasteride 0.05% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tacrolimus 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Finasteride 0.1%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Finasteride 0.1%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.25%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Dutasteride 0.05%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Ketoconazole 2%/Finasteride 0.5% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.01%/Fluocinolone Acetonide 0.01%/Vitamin E Acetate Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 0.5%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 2.5 mg/ml Oral/Sublingual Solution

Add

Adding

Radio 3

CheckboxMinoxidil 1% Topical Solution

Add

Adding

Radio 3

CheckboxMinocycline 50 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMinoxidil 5% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 3% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 0.5%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxMinocycline 100 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMinoxidil 1 mg Capsules

Add

Adding

Radio 3

CheckboxMinocycline 4% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 3%/Finasteride 0.25% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 2%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 1%/Tretinoin 0.025% 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.

Thank you! Your submission has been received!

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