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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

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

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Adding

Radio 3

CheckboxLoratadine 2 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxLorazepam 0.33 mg/Diphenhydramine HCl 12.5 mg/Haloperidol 2 mg Suppository

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Adding

Radio 3

CheckboxLoratadine 1%/Betamethasone 0.5% Topical Gel

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Adding

Radio 3

CheckboxLidocaine HCl 4%/Phenylephrine HCl 1% Nasal Solution

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Adding

Radio 3

CheckboxLoratadine 2 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

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

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Adding

Radio 3

CheckboxLidocaine HCl 10%/Glycerin Nasal Spray

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Adding

Radio 3

CheckboxLorazepam 1 mg/Diphenhydramine HCl 12.5 mg/Haloperidol 2 mg/Metoclopramide 10 mgÂ Suppository

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Adding

Radio 3

CheckboxLidocaine HCl 4%/Tetracaine HCl 0.5%/Epinephrine 0.05% Topical Gel

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Adding

Radio 3

CheckboxLorazepam 1 mgÂ Troche

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Adding

Radio 3

CheckboxLidocaine HCl 10%/Tetracaine HCl 4%/Phenylephrine HCl 1% Nasal Solution

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Adding

Radio 3

CheckboxLorazepam 0.5 mg/0.1 ml Nasal Spray

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Adding

Radio 3

CheckboxLidocaine HCl 2%/Hydrocortisone 1%/Neomycin 3.5 mg/Polymyxin B 10,000 U Suppository

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Adding

Radio 3

CheckboxLidocaine HCl 2%/Hydrocortisone 1% Suppository

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Adding

Radio 3

CheckboxLidocaine HCl 4% Throat Spray

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Adding

Radio 3

CheckboxLidocaine HCl 3% Topical/Vaginal Gel

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Adding

Radio 3

CheckboxLidocaine HCl 4%/Ketamine 2.5% Buffered Nasal Spray

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Adding

Radio 3

CheckboxLidocaine HCl 4% Iontophoresis Solution

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Adding

Radio 3

CheckboxLidocaine HCl 4%/Dexamethasone 0.4% Iontophoresis Solution

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Adding

Radio 3

CheckboxLidocaine HCl 4%/Epinephrine 0.1% Topical Gel

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Adding

Radio 3

CheckboxLidocaine HCl 2% Isotonic Nasal Spray

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Adding

Radio 3

CheckboxLidocaine HCl 4% Isotonic Nasal Spray

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Adding

Radio 3

CheckboxLidocaine HCl 1%/Diphenhydramine HCl 2%/Dexamethasone 0.5%/Cimetidine 4% Topical Gel

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Adding

Radio 3

CheckboxLidocaine HCl 4.42% Isotonic Nasal Spray

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Adding

Radio 3

CheckboxLidocaine HCl 2.5% Topical Gel (Vet)

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Adding

Radio 3

CheckboxLidocaine HCl 2%/Naltrexone HCl 0.5% Oral Rinse

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Adding

Radio 3

CheckboxLidocaine HCl 4%/Dexamethasone 1.5% Ultrasound Gel

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Adding

Radio 3

CheckboxLidocaine HCl 2% Popsicle

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Adding

Radio 3

CheckboxLidocaine HCl 2%/Chlorhexidine Gluconate 0.11% Oral Rinse

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Adding

Radio 3

CheckboxLidocaine HCl 4%/Hydrocortisone 1%/Menthol 0.5% Topical Gel

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Adding

Radio 3

CheckboxLidocaine HCl 2%/Camphor 0.5%/Menthol 0.5% Topical Cream

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Adding

Radio 3

CheckboxLidocaine 30% Topical Ointment

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Adding

Radio 3

CheckboxLidocaine 23%/Tetracaine 7% Topical Gel

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Adding

Radio 3

CheckboxLidocaine 2%/Nitroglycerin 0.2% Rectal Ointment

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Adding

Radio 3

CheckboxLidocaine 3%/Nifedipine 0.4% Rectal Ointment

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Adding

Radio 3

CheckboxLidocaine 33 mg Suppository

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Adding

Radio 3

CheckboxLidocaine 23%/Tetracaine 7% Topical Ointment

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Adding

Radio 3

CheckboxLidocaine 2%/Nifedipine 0.2% Topical/Rectal Ointment

Add

Adding

Radio 3

CheckboxLidocaine 2%/Naltrexone HCl 0.5%/Nifedipine 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine 10%/Prilocaine 10% Topical Ointment

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Adding

Radio 3

CheckboxLidocaine 6%/Tetracaine 6% Topical Ointment

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Adding

Radio 3

CheckboxLidocaine 3%/Diazepam 2%/Nifedipine 0.4% Rectal Ointment

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Adding

Radio 3

CheckboxLidocaine 2%/Nifedipine 0.2% Rectal Ointment

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Adding

Radio 3

CheckboxLidocaine 23%/Tetracaine 7% Topical/Vaginal Cream

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Adding

Radio 3

CheckboxLidocaine 10%/Tetracaine 4%/Prilocaine HCl 10%/Phenylephrine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxLidocaine 2%/Diclofenac Sodium 3%/Cyclobenzaprine HCl 2%/Baclofen 2% Topical Gel

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Adding

Radio 3

CheckboxLidocaine HCl 0.5%/Nystatin 25,000 Units/ml/Diphenhydramine HCl 0.06% Antacid Mouthwash

Add

Adding

Radio 3

CheckboxLidocaine 2%/Atropine Sulfate 1 mg Suppository

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Adding

Radio 3

CheckboxLidocaine HCl 0.5%/Hydrocortisone Acetate 0.1% Rectal Suspension Enema

Add

Adding

Radio 3

CheckboxLidocaine 30% Topical Gel

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Adding

Radio 3

CheckboxLidocaine 2%/Hydrocortisone 1% Suppository

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Adding

Radio 3

CheckboxLidocaine 2%/Hydrocortisone 1% Topical/Rectal

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Adding

Radio 3

CheckboxLidocaine 15%/Bupivacaine 7.5%/Prilocaine 5% Topical Cream

Add

Adding

Radio 3

CheckboxLidocaine 3%/Hydrocortisone Acetate 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxLidocaine 2%/Morphine Sulfate 10 mg/Ketamine HCl 7.5 mg/Diazepam 2.5 mg Suppository

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Adding

Radio 3

CheckboxLevofloxacin 100 mg/Amphotericin B 5 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxLevofloxacin 125 mg/Tobramycin 160 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxLevofloxacin 100 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxLevofloxacin 125 mg/Fluticasone Propionate 3 mg/Itraconazole 50 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxLevofloxacin 4%/Mupirocin 4%/Fluconazole 4%/Ibuprofen 2% Topical Suspension

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Adding

Radio 3

CheckboxLevofloxacin 100 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxLevofloxacin 2%/Mupirocin 4%/Itraconazole 1% Topical Gel

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Adding

Radio 3

CheckboxLevocarnitine 250 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxLevofloxacin 100 mg/Amphotericin B 5 mg/Mometasone Furoate 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxLevofloxacin 125 mg/Amphotericin B 10 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxLevofloxacin 125 mg/Mupirocin 100 mg/Fluticasone Propionate 3 mg/Itraconazole 50 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxLevofloxacin 125 mg/Fluticasone Propionate 3 mg/Fluconazole 15 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxLidocaine 1.5%/Nifedipine 0.3% Topical Ointment

Add

Adding

Radio 3

CheckboxLevofloxacin 125 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxLevofloxacin 50 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxLevofloxacin 50 mg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxLevocarnitine 500 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxLevofloxacin 125 mg/Mupirocin 100 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxLevofloxacin 100 mg/Itraconazole 40 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxLevofloxacin 3%/Mupirocin 5%/Itraconazole 2% Topical Powder

Add

Adding

Radio 3

CheckboxLevofloxacin 125 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxLevofloxacin 25 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxLevofloxacin 4%/Mupirocin 4%/Fluconazole 4%/Clindamycin 4%/Ibuprofen 2% Topical Suspension

Add

Adding

Radio 3

CheckboxLevofloxacin 100 mg/Mometasone Furoate 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxLeucovorin 5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxLansoprazole 3 mg/ml To 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxLecithin 5%/Allantoin 1% Hair Tonic

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Adding

Radio 3

CheckboxLactic Acid/Arbutin 2%/Kojic Acid 1% Topical Cream

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Adding

Radio 3

CheckboxLansoprazole 15 mg Ar Capsules (Gluten Free)

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Adding

Radio 3

CheckboxLeucovorin 5 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxLevetiracetam 100 mg/ml Oral Suspension (Gluten Free)

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Adding

Radio 3

CheckboxLamotrigine 1 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxLamotrigine 100 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxLevetiracetam 40% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxLeflunomide 20 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxLeflunomide 20 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxLeucovorin 10 mg/ml Oral Solution

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Adding

Radio 3

CheckboxLecithin 100 mg/ml Oil Oral Suspension

Add

Adding

Radio 3

CheckboxLactic Acid 1.75% Micropeel Topical Solution

Add

Adding

Radio 3

CheckboxLevetiracetam 100 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxLevetiracetam 500 mg Suppository

Add

Adding

Radio 3

CheckboxLansoprazole 30 mg Ar Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxKetotifen 0.05%/Theanine (L) 0.5% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxKetoprofen 50 mg Suppository

Directions:

QTY:

Refills

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xPrescriber's Signature:

Date

3

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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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