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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

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

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 mgÂ Suppository

Add

Adding

Radio 3

CheckboxHydrocortisone 0.5%/Clioquinol 2% Suppository

Add

Adding

Radio 3

CheckboxHaloperidol 0.06 mg/ml Oral Suspension (Vet)

Add

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

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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