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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

Circle for steps.

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

CheckboxKetamine HCl 10%/Baclofen 2%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Gabapentin 10%/Clonidine HCl 0.2%/Baclofen 2 % Topical Cream

Add

Adding

Radio 3

CheckboxKetamine HCl 3% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 1%/Naltrexone HCl 1% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Clonidine HCl 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Amitriptyline HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Gabapentin 10%/Clonidine HCl 0.2%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Phenytoin 5%/Mexiletine HCl 2%/Clonidine HCl 0.2%/Menthol 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Amitriptyline HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Gabapentin 10%/Tizanidine HCl 0.2%/Baclofen 2% Topical Cream

Add

Adding

Radio 3

CheckboxKetamine 100 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxKetamine 100 mg Troche

Add

Adding

Radio 3

CheckboxKetamine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine 25 mg/Midazolam 3 mg/Ondansetron 2 mg Troche

Add

Adding

Radio 3

CheckboxKetamine 200 mg Troche

Add

Adding

Radio 3

CheckboxKetamine 100 mg Rapid Dissolve Tablet

Add

Adding

Radio 3

CheckboxKetamine 10 mg Capsules

Add

Adding

Radio 3

CheckboxKetamine 50 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxKetamine 0.4% Oral Rinse

Add

Adding

Radio 3

CheckboxKetamine 100 mg/ml Otic Suspension

Add

Adding

Radio 3

CheckboxKetamine 25 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxKetamine 10 mg Troche

Add

Adding

Radio 3

CheckboxKetamine HCl 0.5%/Diazepam 1%/Baclofen 2% Vaginal Gel

Add

Adding

Radio 3

CheckboxKetamine 50 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxKetamine 10 mg Troche

Add

Adding

Radio 3

CheckboxKetamine 200 mg Rapid Dissolve Tablet

Add

Adding

Radio 3

CheckboxKetamine 100 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxKetamine HCl 0.5%/Diazepam 1%/Baclofen 2% Vaginal

Add

Adding

Radio 3

CheckboxKetamine 100 mg/ml/Oxytocin 24 Units/ml Nasal Spray

Add

Adding

Radio 3

CheckboxKetamine 50 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxKetamine 30 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxKetamine HCl 0.5% Vaginal Gel

Add

Adding

Radio 3

CheckboxKetamine 10 mg Rapid Dissolve Tablet

Add

Adding

Radio 3

CheckboxKetamine HCl 1%/Naltrexone HCl 0.1% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxKetamine 7.5 mg Troche

Add

Adding

Radio 3

CheckboxIvermectin 18.7 mg/ml Oral Gel (Vet)

Add

Adding

Radio 3

CheckboxIvermectin 11.4 mg/ml Oral Gel (Vet)

Add

Adding

Radio 3

CheckboxIvermectin 10 mg/ml Oral Solution (Vet)

Add

Adding

Radio 3

CheckboxIvermectin 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxIvermectin 1 mg/0.1 ml Nasal Spray

Add

Adding

Radio 3

CheckboxItraconazole 150 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxIvermectin 1%/Ketotifen 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxItraconazole 50 mg Capsules

Add

Adding

Radio 3

CheckboxIvermectin 3 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxItraconazole 8%/Flurbiprofen 2%/Levofloxacin 2% Topical Suspension

Add

Adding

Radio 3

CheckboxIvermectin 0.1 mg/0.1 ml Topical Cream (Vet)

Add

Adding

Radio 3

CheckboxItraconazole 20 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxIvermectin 1% Topical Lotion

Add

Adding

Radio 3

CheckboxIvermectin 1%/Metronidazole 0.75% Topical Gel

Add

Adding

Radio 3

CheckboxIvermectin 1% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxItraconazole 250 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxIvermectin 1 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxItraconazole 5%/Mupirocin 5%/Fluticasone Propionate 1%/Urea 40% Topical Gel

Add

Adding

Radio 3

CheckboxItraconazole 30 mg Capsules

Add

Adding

Radio 3

CheckboxItraconazole 125 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxIvermectin 1%/Brimonidine Tartrate 0.5%/Ketotifen 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxItraconazole 3%/Tea Tree Oil 5% Scalp Gel

Add

Adding

Radio 3

CheckboxItraconazole 50 mg/Vancomycin 50 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxItraconazole 40 mg Capsules

Add

Adding

Radio 3

CheckboxItraconazole 5%/Fluticasone Propionate 1% Topical Gel

Add

Adding

Radio 3

CheckboxItraconazole 50 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxIodoform 5% Compound Topical Ointment

Add

Adding

Radio 3

CheckboxImiquimod 6 mg Suppository

Add

Adding

Radio 3

CheckboxItraconazole 1% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxItraconazole 1%/Undecylenic Acid 17%/Tea Tree Oil 17%/Salicylic Acid 10% in DMSO Nail Solution

Add

Adding

Radio 3

CheckboxItraconazole 0.01% Nasal Suspension

Add

Adding

Radio 3

CheckboxIodoquinol 130 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxIodoquinol 100 mg/Boric Acid 150 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxIodoquinol 1%/Hydrocortisone 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxItraconazole 1% Topical Ointment (Vet)

Add

Adding

Radio 3

CheckboxImiquimod 5%/Diclofenac Sodium 3% Topical Cream

Add

Adding

Radio 3

CheckboxItraconazole 1%/Undecylenic Acid 17%/Tea Tree Oil 17% in DMSO Nail Solution

Add

Adding

Radio 3

CheckboxIodoquinol 1%/Azelastine HCl 0.1%/Clotrimazole 1%/Hydrocortisone 1% Topical Cream

Add

Adding

Radio 3

CheckboxIodoquinol 60 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxItraconazole 0.2%/Mupirocin 0.2%/Triamcinolone 0.03% Nasal Spray

Add

Adding

Radio 3

CheckboxIodoquinol 325 mg Capsules

Add

Adding

Radio 3

CheckboxItraconazole 0.1% Nasal Suspension

Add

Adding

Radio 3

CheckboxImiquimod 5%/Egcg 1% Topical Gel

Add

Adding

Radio 3

CheckboxImiquimod 5%/Diclofenac Sodium 1% Topical Cream

Add

Adding

Radio 3

CheckboxImipramine HCl 150 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxIbuprofen 20%/Piroxicam 1% Topical Gel

Add

Adding

Radio 3

CheckboxIbuprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxImiquimod 5%/Deoxy-D-Glucose 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxIbuprofen 800 mg Suppository

Add

Adding

Radio 3

CheckboxIchthammol 12% Topical Ointment

Add

Adding

Radio 3

CheckboxImiquimod 0.5% Vaginal Gel

Add

Adding

Radio 3

CheckboxIbuprofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxIbuprofen 400 mg/ Caffeine 60mg Suppository

Add

Adding

Radio 3

CheckboxIbuprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxIbuprofen 200 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxImiquimod 5% Topical Gel

Add

Adding

Radio 3

CheckboxIbuprofen 2%/Itraconazole 1%/DMSO Nail Solution

Add

Adding

Radio 3

CheckboxIbuprofen 100 mg Popsicle

Add

Adding

Radio 3

CheckboxIbuprofen 400 mg/5 ml Oral Suspension (Gluten Free)

Add

Adding

Radio 3

CheckboxIbuprofen 400 mg/Colchicine 0.6 mg Capsules

Add

Adding

Radio 3

CheckboxIbuprofen 600 mg Suppository

Add

Adding

Radio 3

CheckboxIbuprofen 5% Topical Gel

Add

Adding

Radio 3

CheckboxIbuprofen 400 mg Suppository

Add

Adding

Radio 3

CheckboxIbuprofen 20%/Cyclobenzaprine 1%/Piroxicam 1% Topical Gel

Add

Adding

Radio 3

CheckboxHydroxychloroquine Sulfate 200 mg Capsules (Gluten Free)

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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