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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

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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

CheckboxHydrocortisone 1%/Menthol 0.5% Scalp Lotion

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Nystatin 2000 U/Gm/Mupirocin 2%/Boric Acid Otic Powder

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Glycolic Acid 30% Topical Lotion

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Gentamicin 3.2 mg/ml/Polymyxin B 10,000 U/ml Otic Solution (Vet)

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Nystatin 33,333 Units/Gm/Zinc Oxide Topical Ointment

Add

Adding

Radio 3

CheckboxHydrocortisone 2.5 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Zinc Oxide 0.5% Suppository

Add

Adding

Radio 3

CheckboxHydrocortisone 2.5 mg Capsules

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Neomycin 0.35% Otic Suspension

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Neomycin 3.5 mg/ml/Polymyxin B 10,000 U/ml Otic Solution

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Neomycin 3.5 mg/ml/Polymyxin B 10,000 U/ml Otic Suspension

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Lidocaine HCl 0.5%/Neomycin 0.35%/Polymyxin B 10,000 U/ml Otic Solution

Add

Adding

Radio 3

CheckboxHydrocortisone 2 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Benzoyl Peroxide 5% Topical Lotion

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Adding

Radio 3

CheckboxHydrocortisone 1%/Salicylic Acid 0.5% Scalp Lotion

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Neomycin 10 mg/ml/Benzocaine 0.5%/Polymyxin B 3000 U/ml/Bacitracin 500 U/ml Oral Gel

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Neomycin 3.5 mg/ml/Gentamicin 1.7 mg/ml/Polymyxin B 10,000 U/ml Otic Solution

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Menthol 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Neomycin 3.5 mg/Gm/Polymyxin B 10,000 U/Gm Topical Cream

Add

Adding

Radio 3

CheckboxGuaifenesin 500 mg Suppository

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Acetic Acid 2% Otic Solution

Add

Adding

Radio 3

CheckboxHydrocodone Bitartrate 5 mg/Acetaminophen 500 mg Suppository

Add

Adding

Radio 3

CheckboxHydrocortisone 0.5%/Clioquinol 2% Suppository

Add

Adding

Radio 3

CheckboxHaloperidol 0.06 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxHaloperidol 2 mg/ml Oral Solution (Gluten Free/Flavored)

Add

Adding

Radio 3

CheckboxHydrocodone Bitartrate 20 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxHydrocortisone 0.6%/Salicylic Acid 0.48% Topical Solution

Add

Adding

Radio 3

CheckboxHaloperidol 1% Topical Solution

Add

Adding

Radio 3

CheckboxHydrocortisone 1 mg/ml To 20 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxHydrocodone Bitartrate 10 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxHydrocortisone 1%/Aluminum Acetate Poloxamer Otic Gel

Add

Adding

Radio 3

CheckboxHydrocortisone 1% Otic Solution

Add

Adding

Radio 3

CheckboxHaloperidol 1 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxGuaifenesin 600 mg Suppository

Add

Adding

Radio 3

CheckboxGuaifenesin 200 mg Suppository

Add

Adding

Radio 3

CheckboxGuanfacine 1 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxHydrocortisone 0.5%/Polymyxin B 10,000 U/ml Otic Solution

Add

Adding

Radio 3

CheckboxHaloperidol 50 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxGuaifenesin 400 mg Suppository

Add

Adding

Radio 3

CheckboxHydrochlorothiazide 5 mg/ml To 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxHydrocortisone 0.5%/Progesterone 0.2%/Dutasteride 0.05%/Tretinoin 0.01% Topical Solution

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Ketoprofen 10%/Capsaicin 0.05%/Lidocaine HCl 4% Topical Gel

Add

Adding

Radio 3

CheckboxGuaifenesin 5%/Dextromethorphan HBr 5% Ultrasound Gel

Add

Adding

Radio 3

CheckboxGlycopyrrolate 1% Topical Cream

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Magnesium Sulfate Heptahydrate 10% Topical Gel

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Ketoprofen 10%/Amitriptyline HCl 2%/Lidocaine 2%/Capsaicin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxGlycopyrrolate 0.1 mg/0.25 ml Topical Gel

Add

Adding

Radio 3

CheckboxGlycopyrrolate 0.5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxGuaifenesin 100 mg Suppository

Add

Adding

Radio 3

CheckboxGlycopyrrolate 0.5% Topical Solution

Add

Adding

Radio 3

CheckboxGuaifenesin 2% Topical Cream

Add

Adding

Radio 3

CheckboxGlycopyrrolate 0.5 mg/ml Oral Rinse

Add

Adding

Radio 3

CheckboxGlycopyrrolate 3% Topical Lotion

Add

Adding

Radio 3

CheckboxGuaifenesin 10% Topical Gel

Add

Adding

Radio 3

CheckboxGuaifenesin 10% Topical Cream

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Magnesium Chloride Hexahydrate 10%/Diclofenac Sodium 5%/Piroxicam 2% Topical Gel

Add

Adding

Radio 3

CheckboxGuaifenesin 10%/Magnesium Chloride Hexahydrate 10% Topical Gel

Add

Adding

Radio 3

CheckboxGuaifenesin 15%/Ketoprofen 10%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxGuaifenesin 50 mg/Baclofen 20 mg/Cyclobenzaprine HCl 20 mg Suppository

Add

Adding

Radio 3

CheckboxGlycopyrrolate 1%/Tea Tree Oil 2.5% Topical Stick

Add

Adding

Radio 3

CheckboxGlycopyrrolate 4 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxGlipizide 2.5 mg/0.1 ml Topical Lipoderm® (Vet)

Add

Adding

Radio 3

CheckboxGlutathione 250 mg Troche

Add

Adding

Radio 3

CheckboxGlucosamine Sulfate 10% Topical Gel

Add

Adding

Radio 3

CheckboxGlipizide 5 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxGlutathione 20% Topical Cream

Add

Adding

Radio 3

CheckboxGlutathione 5%/Aluminum Chlorohydrate 10% Topical Lotion

Add

Adding

Radio 3

CheckboxGlipizide 5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxGlutamine 1 Gm/5 ml Oral Suspension

Add

Adding

Radio 3

CheckboxGlutathione 20% Topical Gel

Add

Adding

Radio 3

CheckboxGlycolic Acid 8%/Lactic Acid 9%/Urea 10% Topical Gel

Add

Adding

Radio 3

CheckboxGlutathione 200 mg Troche

Add

Adding

Radio 3

CheckboxGlutathione 500 mg Capsules

Add

Adding

Radio 3

CheckboxGlycolic Acid 8%/Lactic Acid 7% Topical Day Gel

Add

Adding

Radio 3

CheckboxGlutathione 500 mg Suppository

Add

Adding

Radio 3

CheckboxGlipizide 5 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxGlycolic Acid 8%/Salicylic Acid 2% Topical Solution

Add

Adding

Radio 3

CheckboxGlutathione 200 mg Capsules

Add

Adding

Radio 3

CheckboxGlutamine 2 Gm/5 ml Mouthwash

Add

Adding

Radio 3

CheckboxGlutathione 10% Topical Cream

Add

Adding

Radio 3

CheckboxGlutathione 6% Nasal Spray

Add

Adding

Radio 3

CheckboxGlipizide 10 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxGlutathione 10%/Ascorbic Acid 5% Topical Cream

Add

Adding

Radio 3

CheckboxGentamicin 20 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentamicin 80 mg/Fluconazole 15 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentamicin 20 mg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentamicin 80 mg/Clotrimazole 10 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentamicin 80 mg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentian Violet 0.4% Vaginal Gel

Add

Adding

Radio 3

CheckboxGentian Violet 100 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxGentian Violet 0.1% Vaginal Gel

Add

Adding

Radio 3

CheckboxGentamicin 80 mg/Mupirocin 20 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentamicin 15mg mg/ml Ophthalmic Solution (Fortified)

Add

Adding

Radio 3

CheckboxGentamicin 80 mg/Fluconazole 15 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentamicin 20 mg/Mupirocin 15 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentian Violet 60 mg Capsules

Add

Adding

Radio 3

CheckboxGentamicin 80 mg/Betamethasone 0.75 mg Capsules

Add

Adding

Radio 3

CheckboxGentamicin 20 mg/Mupirocin 5 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentamicin 80 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxGentamicin 80 mg/Mupirocin 30 mg/Edetate Disodium 15 mg Capsules (For Nasal Irrigation/Nebulizer)

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

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Thank you! Your submission has been received!

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