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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

CheckboxMethylphenidate HCl 20 mg Slow Release CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxMethotrexate 2.5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMethyl Salicylate 16%/Eucalyptus 1%/Menthol 1% Topical Cream

Add

Adding

Radio 3

CheckboxMethylcobalamin 1 mg/ml To 20 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxMethyl Salicylate 30%/Menthol 3% Topical Cream

Add

Adding

Radio 3

CheckboxMethylcobalamin 25 mg/Gm Topical Cream

Add

Adding

Radio 3

CheckboxMethotrexate 1% Topical Cream

Add

Adding

Radio 3

CheckboxMethyl Salicylate 10%/Camphor 3%/Menthol 1% Topical Analgesic Ointment

Add

Adding

Radio 3

CheckboxMethyl Salicylate 4.9%/Camphor 2%/Menthol 1% Topical Lotion

Add

Adding

Radio 3

CheckboxMethyl Salicylate 30% Compound Topical Rub

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Adding

Radio 3

CheckboxMethylphenidate HCl 1 mg/ml Oral SuspensionÂ (Gluten Free)

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Adding

Radio 3

CheckboxMethylphenidate HCl 10 mg Slow Release CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxMethyl Salicylate 14%/Menthol 3% Topical Lotion

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Adding

Radio 3

CheckboxMethyl Salicylate 20% Topical Gel

Add

Adding

Radio 3

CheckboxMethylphenidate HCl 15 mg Slow Release CapsulesÂ (Gluten Free)

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Adding

Radio 3

CheckboxMethimazole 10 mg/ml Suspension (Vet)

Add

Adding

Radio 3

CheckboxMethyl Salicylate 30%/Camphor 6%/Menthol 3% Topical Lotion

Add

Adding

Radio 3

CheckboxMethyl Salicylate 15%/Menthol 10% Topical Cream

Add

Adding

Radio 3

CheckboxMethotrexate 0.025% Topical Cream

Add

Adding

Radio 3

CheckboxMethylcobalamin 2 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxMethotrexate 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxMethadone HCl 100 mg CapsulesÂ (Gluten Free)

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Adding

Radio 3

CheckboxMetformin HCl 20% Topical Gel

Add

Adding

Radio 3

CheckboxMethadone HCl 40 mg CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxMethenamine 5% Topical Gel

Add

Adding

Radio 3

CheckboxMetformin HCl 30% Topical Lotion

Add

Adding

Radio 3

CheckboxMetformin HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxMethadone HCl 60 mg CapsulesÂ (Gluten Free)

Add

Adding

Radio 3

CheckboxMethimazole 5 mg/ml Suspension (Vet)

Add

Adding

Radio 3

CheckboxMethimazole 2.5 mg/0.1 ml To 10 mg/0.1 ml Topical Gel (Vet)

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Adding

Radio 3

CheckboxMethadone HCl 80 mg CapsulesÂ (Gluten Free)

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Adding

Radio 3

CheckboxMetformin HCl 10% Vaginal Gel

Add

Adding

Radio 3

CheckboxMethenamine 5%/Benzalkonium Chloride 2%/Chlorhexidine Gluconate 0.5% Topical Solution

Add

Adding

Radio 3

CheckboxMethenamine 40.8 mg/Atropine Sulfate 0.03 mg/Hyoscyamine Sulfate 0.03 mg Capsules

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Adding

Radio 3

CheckboxMetformin HCl 5%/Progesterone 1%/Spironolactone 2% Topical Gel

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Adding

Radio 3

CheckboxMetformin HCl 100 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxMetformin HCl 100 mg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxMethadone HCl 20 mg CapsulesÂ (Gluten Free)

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Adding

Radio 3

CheckboxMethenamine 81.6 mg/Atropine Sulfate 0.06 mg/Hyoscyamine Sulfate 0.06 mg Capsules

Add

Adding

Radio 3

CheckboxMetformin HCl 5%/Spironolactone 5%/Progesterone 1% Topical Gel

Add

Adding

Radio 3

CheckboxMeloxicam 0.09%/Lamotrigine 2.5%/Lidocaine 2%/Prilocaine HCl 2% Topical Gel

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Adding

Radio 3

CheckboxMetformin HCl 5%/Azelaic Acid 1%/Progesterone 1% Topical Cream

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Adding

Radio 3

CheckboxMesalamine 4 Gm/60 ml/Budesonide 2 mg/60 ml Enema

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Adding

Radio 3

CheckboxMesalamine 250 mg Suppository

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Adding

Radio 3

CheckboxMequinol 2%/Tretinoin 0.01% Topical Solution

Add

Adding

Radio 3

CheckboxMetformin HCl 2%/Spironolactone 2%/Testosterone 0.05%/Progesterone 5% Topical Cream

Add

Adding

Radio 3

CheckboxMesalamine 250 mg Capsules

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Adding

Radio 3

CheckboxMemantine HCl 2 mg/ml Oral Suspension (Gluten Free)

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Adding

Radio 3

CheckboxMeloxicam 1.5 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxMesalamine 200 mg Capsules

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Adding

Radio 3

CheckboxMesalamine 400 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMesalamine 250 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxMesalamine 1.2 Gm/60 ml Rectal Suspension Enema

Add

Adding

Radio 3

CheckboxMesalamine 200 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxMesalamine 50 mg/Sodium Butyrate Slow Release Ar Capsules

Add

Adding

Radio 3

CheckboxMesalamine 4 Gm/60 ml/Budesonide 4 mg/60 ml Retention Enema

Add

Adding

Radio 3

CheckboxMeloxicam 0.5 mg/ml/Glucosamine Sulfate Sodium Chloride 200 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxMesalamine 4 Gm/Sodium Butyrate 100 Mm Retention Enema

Add

Adding

Radio 3

CheckboxMagnesium Sulfate Heptahydrate 40% Oral Solution

Add

Adding

Radio 3

CheckboxMagnesium Chloride 10%/Naltrexone HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxMagnesium Chloride Hexahydrate 10%/Baclofen 2% Topical Cream

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Adding

Radio 3

CheckboxMelatonin 20 mg Capsules

Add

Adding

Radio 3

CheckboxMagnesium Chloride Hexahydrate 10% Topical Gel

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Adding

Radio 3

CheckboxMagnesium 40 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxMagnesium Sulfate Heptahydrate 20% Topical Gel

Add

Adding

Radio 3

CheckboxMagnesium Gluconate 200 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxMagnesium Sulfate 2% Topical Cream

Add

Adding

Radio 3

CheckboxMefenamic Acid 250 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMedroxyprogesterone Acetate 2.5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMelatonin 5 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxMagnesium Gluconate 500 mg Suppository

Add

Adding

Radio 3

CheckboxMelatonin 5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMagnesium Chloride Hexahydrate 10%/Naltrexone HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxMedroxyprogesterone Acetate 5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMelatonin 3 mg/Naltrexone HCl 3 mg Capsules

Add

Adding

Radio 3

CheckboxMedroxyprogesterone Acetate 10 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMagnesium Sulfate Heptahydrate 10% Topical Gel

Add

Adding

Radio 3

CheckboxLorazepam 1 mg/ml/Diphenhydramine HCl 12.5 mg/ml/Haloperidol 2 mg/ml/Metoclopramide 20 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxLubiprostone 24 Mcg/2.5 ml Oral Solution

Add

Adding

Radio 3

CheckboxLosartan Potassium 10 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxLorazepam 1 mg/ml/Diphenhydramine HCl 12.5 mg/ml/Haloperidol 2 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxLorazepam 5 mg/Gm Topical Lipoderm Gel

Add

Adding

Radio 3

CheckboxLorazepam 1 mg/Gm Topical Cream

Add

Adding

Radio 3

CheckboxLosartan Potassium 2.5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxLovastatin 2%/Cholesterol Topical Gel

Add

Adding

Radio 3

CheckboxLysine HCl 250 mg/ml Oral Solution (Vet)

Add

Adding

Radio 3

CheckboxLorazepam 1 mg/Diphenhydramine HCl 12.5 mg/Haloperidol 2 mg/Metoclopramide 40 mgÂ Suppository

Add

Adding

Radio 3

CheckboxLidocaine HCl 5%/Polymyxin B 10,000 U/ml Otic Solution

Add

Adding

Radio 3

CheckboxLidocaine HCl 10%/Tetracaine HCl 4%/Phenylephrine HCl 2% Topical Solution

Add

Adding

Radio 3

CheckboxLipoic Acid 1%/Vitamin E Acetate 3%/Aloe Topical Cream

Add

Adding

Radio 3

CheckboxLidocaine HCl 10%/Tetracaine HCl 4% Nasal Gel

Add

Adding

Radio 3

CheckboxLorazepam 1 mg/Diphenhydramine HCl 12.5 mg/Haloperidol 2 mg/Metoclopramide 20 mgÂ Suppository

Add

Adding

Radio 3

CheckboxLidocaine HCl 15%/Prednisolone 0.5%/Eugenol Compound Socket Paste

Add

Adding

Radio 3

CheckboxLidocaine HCl 10%/Amitriptyline HCl 5%/Cyclobenzaprine HCl 5% Iontophoresis Solution

Add

Adding

Radio 3

CheckboxLisinopril 2 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxLidocaine HCl 4%/Phenylephrine HCl 1%/Glycerin 5% Nasal Solution

Add

Adding

Radio 3

CheckboxLipoic Acid 1% Vaginal Cream

Add

Adding

Radio 3

CheckboxLidocaine HCl 5% Vaginal Gel

Add

Adding

Radio 3

CheckboxLidocaine HCl 10%/Tetracaine HCl 4% Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine HCl 30% Topical Cream

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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