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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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Visit the Tutorials tab to learn more.

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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

CheckboxDiphenhydramine HCl 1 mg/mL/Lidocaine HCl 10 mg/mL/Misoprostol 0.024 mg/mL/Triamcinolone Acetonide 1.2 mg/mL Oral Rinse

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Adding

Radio 3

CheckboxDiphenhydramine HCl 1 mg/mL/Lidocaine HCl 10 mg/mL/Misoprostol 0.024 mg/mL Oral Suspension

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Adding

Radio 3

CheckboxDiphenhydramine HCl 1 mg/mL/Doxycycline Hyclate 2 mg/mL/Hydrocortisone 1.0 mg/mL Oral Suspension

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Adding

Radio 3

CheckboxDimethyl Sulfoxide 50% Topical Cream

Add

Adding

Radio 3

CheckboxDimethyl Sulfone 16% Nasal Solution

Add

Adding

Radio 3

CheckboxDiltiazem HCl 50 mg/g Topical Gel

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Adding

Radio 3

CheckboxDiltiazem HCl 12 mg/mL Oral Syrup

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 2 mg Slow Release (ME4M) Oral Capsules

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Adding

Radio 3

CheckboxDicyclomine HCl 10 mg/Doxylamine Succinate 10 mg/Pyridoxine HCl 10 mg Capsules

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 1 mg Troches

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Adding

Radio 3

CheckboxDiclofenac Sodium 15 mg/mL Oral Suspension

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Adding

Radio 3

CheckboxDiazepam 5 mg/Metoclopramide HCl 10 mg/Promethazine HCl 25 mg Suppositories

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Adding

Radio 3

CheckboxDiazepam 1 mg/mL Rectal Gel

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Adding

Radio 3

CheckboxDextromethorphan HBr 40 mg/g/Diclofenac Na 80 mg/g/Piroxicam 40 mg/g Topical Cream

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Adding

Radio 3

CheckboxDextromethorphan HBr 10%/Guaifenesin 10%/Urea 8% Topical Gel

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Adding

Radio 3

CheckboxDexpanthenol 50 mg/mL/Piroxicam 5 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxDexpanthenol 50 mg/g Topical Gel Cream

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Adding

Radio 3

CheckboxDexpanthenol 5% Topical Gel

Add

Adding

Radio 3

CheckboxDexpanthenol 5% Nasal Spray

Add

Adding

Radio 3

CheckboxDexpanthenol 2.5%/Tretinoin 0.05% Topical Gel

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Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 5.28 mg/mL/Lidocaine HCl 40 mg/mL Solution for Iontophoresis

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Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 1.6 mg/mL/Verapamil HCl 1 mg/mL Solution for Iontophoresis

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Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 1.6 mg/mL/Lidocaine HCl 8 mg/mL/Verapamil HCl 1 mg/mL Solution for Iontophoresis

Add

Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 1.6 mg/mL/Lidocaine HCl 8 mg/mL Solution for Iontophoresis

Add

Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 1 mg/mL Solution for Iontophoresis

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Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 0.2%/Tetracycline HCl 2.4% Periodontal Gel

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Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 0.2%/Metronidazole Benzoate 10% Periodontal Gel

Add

Adding

Radio 3

CheckboxDexamethasone Sodium Phosphate 0.05%/Diphenhydramine HCl 1%/Quinine Sulfate 0.1% Topical Gel

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Adding

Radio 3

CheckboxDexamethasone 5 mg/Diphenhydramine HCl 25 mg/Metoclopramide HCl 20 mg Suppositories

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Adding

Radio 3

CheckboxDexamethasone 4 mg/mL/Lidocaine HCl 20 mg/mL Ultrasound Gel

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Adding

Radio 3

CheckboxDexamethasone 4 mg/mL Solution for Iontophoresis

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Adding

Radio 3

CheckboxDexamethasone 20 mg/mL/Piroxicam 1 mg/mL Topical Gel

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Adding

Radio 3

CheckboxDexamethasone 10 mg/mL/Piroxicam 1 mg/mL Topical Gel

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Adding

Radio 3

CheckboxDexamethasone 10 mg/Diphenhydramine HCl 25 mg/Metoclopramide HCl 20 mg Suppositories

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Adding

Radio 3

CheckboxDexamethasone 10 mg/Diphenhydramine HCl 25 mg/Haloperidol 1 mg/Metoclopramide HCl 20 mg Suppositories

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Adding

Radio 3

CheckboxDexamethasone 1.5%/Lidocaine HCl 4% Ultrasound Gel

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Adding

Radio 3

CheckboxDexamethasone 1.2%/Diphenhydramine HCl 2.4%/Haloperidol 0.1%/Lorazepam 0.1%/Metoclopramide HCl 2.4% Topical Gel

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Adding

Radio 3

CheckboxDexamethasone 1 mg/g Topical Cream

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Adding

Radio 3

CheckboxDexamethasone 0.4% Ultrasound Gel

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Adding

Radio 3

CheckboxDexamethasone 0.25 mg/2.5 mL/Tacrolimus 0.25 mg/2.5 mL Oral Suspension

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Radio 3

CheckboxDexamethasone 0.1%/Hydroquinone 5%/Retinoic Acid 0.1% Topical Ointment

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Radio 3

CheckboxDexamethasone 0.04% Topical Spray

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Adding

Radio 3

CheckboxDeoxy-D-glucose 2 mg/g/Xylitol 50 mg/mL Nasal Solution

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Adding

Radio 3

CheckboxDeoxy-D-glucose 2 mg/g/Lidocaine HCl 50 mg/mL Topical Cream

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Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg/Pregnenolone 20 mg Capsules

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Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg Capsules

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Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg/2 g Topical Lotion

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Adding

Radio 3

CheckboxDehydroepiandrosterone 15 mg/Testosterone 2 mg Troches

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Adding

Radio 3

CheckboxDehydroepiandrosterone 10 mg Vaginal Suppositories

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Adding

Radio 3

CheckboxDehydroepiandrosterone 1%/Levocarnitine 2% Topical Cream

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Adding

Radio 3

CheckboxDapsone 15 mg/mL Oral Solution

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Adding

Radio 3

CheckboxDantrolene Sodium 5 mg/mL Oral Syrup

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Adding

Radio 3

CheckboxCyclosporine A 2%/Ketoprofen 2.5%/Phenylephrine HCl 0.1% Topical Cream

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Adding

Radio 3

CheckboxCyclosporine A 2% Topical Gel

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Adding

Radio 3

CheckboxClotrimazole 10 mg/mL/Tetracaine 10 mg/mL Otic Suspension

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Adding

Radio 3

CheckboxCoal Tar 0.4% Topical Gel

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Adding

Radio 3

CheckboxClonidine HCl 1 mg/g Topical Gel

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Adding

Radio 3

CheckboxCoal Tar 6%/Zinc Oxide 6% Topical Paste

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Adding

Radio 3

CheckboxCitalopram HBr 20 mg/g Topical Cream

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Adding

Radio 3

CheckboxCoal Tar Solution 0.5% Topical Gel

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Adding

Radio 3

CheckboxCyclosporine 20 mg/mL Ophthalmic Solution

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Adding

Radio 3

CheckboxCoal Tar Solution 2%/Hydrocortisone 1.2% Topical Lotion

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Adding

Radio 3

CheckboxChlorambucil 0.5 mg Capsules

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Adding

Radio 3

CheckboxCyclobenzaprine HCl 5 mg/mL/Ketamine HCl 46 mg/mL/Ketoprofen 100 mg/mL Topical Gel

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Adding

Radio 3

CheckboxCromolyn Sodium 50 mg/mL Oral Suspension

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Adding

Radio 3

CheckboxClopidogrel Bisulfate 5 mg/mL Oral Suspension

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Adding

Radio 3

CheckboxCoenzyme Q10 200 mg Troches

Add

Adding

Radio 3

CheckboxClindamycin Phosphate 1.2%/Tretinoin 0.025% Topical Cream

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Adding

Radio 3

CheckboxCromolyn Sodium 4% Topical Cream

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Gabapentin 6%/Ketamine HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxCetirizine Dihydrochloride 10 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxClonazepam 0.25 mg/2 mL Oral Gel

Add

Adding

Radio 3

CheckboxCoal Tar Solution 2%/Salicylic Acid 5% Topical Cream

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Ibuprofen 2%/Metronidazole 2%/Nifedipine 0.2%/Dexpanthenol 3% Topical Cream

Add

Adding

Radio 3

CheckboxChlorpromazine HCl 50 mg/mL Topical Spray

Add

Adding

Radio 3

CheckboxClindamycin HCl 22.7 mg/Clotrimazole 100 mg Vaginal Suppositories

Add

Adding

Radio 3

CheckboxCyclomethicone 10% Topical Lotion

Add

Adding

Radio 3

CheckboxClomipramine HCl 2.5 mg Capsules

Add

Adding

Radio 3

CheckboxCoal Tar Solution 3%/Hydrocortisone 0.5% Topical Lotion

Add

Adding

Radio 3

CheckboxCoenzyme Q10 50 mg Troches

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 0.5%/Naproxen 10% Topical Gel

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Adding

Radio 3

CheckboxClotrimazole 10 mg/mL/Ketoconazole 22.2 mg/mL Nail Solution

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.5 mg/mL/Pyrithione Zinc 2 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxCyclophosphamide 25 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxClindamycin Phosphate 50 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxCevimeline HCl 30 mg/10 mL Oral Solution

Add

Adding

Radio 3

CheckboxCiprofloxacin 1% Otic Solution

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05%/Pyrithione Zinc 2% Topical Spray

Add

Adding

Radio 3

CheckboxClotrimazole 1% Scalp Solution

Add

Adding

Radio 3

CheckboxClonazepam 0.2 mg/mL Mouthwash

Add

Adding

Radio 3

CheckboxChlorambucil 2 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Ibuprofen 2%/Metronidazole 2% Topical Powder

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 20 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxCodeine Sulfate 15 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 0.2% Oral Rinse

Add

Adding

Radio 3

CheckboxChlorpromazine HCl 25 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxCholestyramine 6.5% Topical Ointment

Add

Adding

Radio 3

CheckboxChloroquine Phosphate 500 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.5 mg/mL/Pyrithione Zinc 2 mg/mL 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.

Thank you! Your submission has been received!

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