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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

CheckboxGentamicin 80 mg/Mupirocin 20 mg/Clotrimazole 10 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

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

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Adding

Radio 3

CheckboxGentian Violet 2% Topical Solution

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Adding

Radio 3

CheckboxGabapentin 100 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxGabapentin 250 mg/Pyridoxine HCl 10 mg Capsules

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Adding

Radio 3

CheckboxGabapentin 100 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxGabapentin 500 mg/Pyridoxine HCl 10 mg Capsules

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Adding

Radio 3

CheckboxGentamicin 0.008%/Mupirocin 0.2%/Edetate Disodium 0.1% Nasal Spray

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Adding

Radio 3

CheckboxGabapentin 400 mg/5 ml Oral Suspension

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Adding

Radio 3

CheckboxGentamicin 0.57 mg/ml/Betamethasone 0.284 mg/ml Topical Spray (Vet)

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Adding

Radio 3

CheckboxGentamicin 4 mg/ml/Betamethasone 1 mg/ml Otic Solution

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Adding

Radio 3

CheckboxGabapentin 15%/Lidocaine HCl 3%/Prilocaine HCl 3% Topical Gel

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Adding

Radio 3

CheckboxGentamicin 0.4 mg/0.2 Gm/Betamethasone 0.2 mg/0.2 Gm Topical Gel (Vet)

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Adding

Radio 3

CheckboxGabapentin 200 mg/5 ml Oral Suspension

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Adding

Radio 3

CheckboxGentamicin 1% Topical Gel (Vet)

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Adding

Radio 3

CheckboxGabapentin 120 mg/Gm/Belladonna Extract 16 mg/Gm Vaginal Gel

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Adding

Radio 3

CheckboxGabapentin 25 mg/ml To 100 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxGentamicin 0.25%/Itraconazole 0.2%/Mupirocin 0.2%/Edetate Disodium 0.1% Nasal Spray

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Adding

Radio 3

CheckboxGentamicin 0.25 mg/ml Nasal Flush

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Adding

Radio 3

CheckboxGentamicin 3 mg/Gm/Betamethasone 1 mg/Gm Otic Ointment (Vet)

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Adding

Radio 3

CheckboxGabapentin 6%/Acetaminophen 5% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 5% Oral Rinse

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Adding

Radio 3

CheckboxGabapentin 6% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 6%/Lidocaine HCl 2% Vaginal Gel

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Adding

Radio 3

CheckboxGabapentin 6%/Acetaminophen 5% Topical Cream

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Adding

Radio 3

CheckboxGabapentin 10%/Lidocaine 2%/Prilocaine 2% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 6% Iontophoresis Solution

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Adding

Radio 3

CheckboxGabapentin 10%/Menthol 5%/Camphor 2%/Lidocaine 2%/Capsaicin 0.05% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 10%/Amantadine HCl 8%/Bupivacaine HCl 5%/Imipramine HCl 3%/Nifedipine 2% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 10%/Clonidine HCl 0.2%/Baclofen 1% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 10%/Ketoprofen 5%/Acyclovir 2%/Amitriptyline HCl 2%/Tetracaine 1% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 6%/Ketamine 3%/Amitriptyline HCl 2%/Lidocaine HCl 0.5% Oral Rinse

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Adding

Radio 3

CheckboxGabapentin 10%/Ketoprofen 5%/Amitriptyline HCl 2%/Lidocaine 1% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 6%/Amitriptyline HCl 2%/Lidocaine 1% Topical Scalp Solution

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Adding

Radio 3

CheckboxGabapentin 6%/Lidocaine 2.5%/Baclofen 2%/Cyclobenzaprine HCl 2%/Ketoprofen 2% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 5 mg/0.1 ml Topical Gel (Vet)

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Adding

Radio 3

CheckboxGabapentin 12 mg Capsules (Vet)

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Adding

Radio 3

CheckboxGabapentin 5%/Amitriptyline HCl 2%/Lidocaine 2% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 6%/Lidocaine 2%/Prilocaine HCl 2%/Meloxicam 0.09% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 6%/Clonidine HCl 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 10%/Amantadine HCl 8%/Diclofenac Sodium 5%/Baclofen 2%/Lidocaine 2% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 6%/Estriol 0.1%/Testosterone 0.1% VaginalÂ Gel

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Adding

Radio 3

CheckboxGabapentin 6% Vaginal Gel

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Adding

Radio 3

CheckboxGabapentin 10 mg/0.1 ml Topical Gel (Vet)

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Adding

Radio 3

CheckboxGabapentin 6%/Naltrexone HCl 1% Topical Gel

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Adding

Radio 3

CheckboxGabapentin 6%/Acyclovir 5%/Ketoprofen 5%/Amitriptyline HCl 2%/Bupivacaine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxGabapentin 6%/Ketamine HCl 2.5%/Lidocaine HCl 2% Vaginal Gel

Add

Adding

Radio 3

CheckboxFluticasone Propionate 1%/Urea 40% Topical Gel

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Adding

Radio 3

CheckboxFluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxFurosemide 10 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxFluticasone Propionate 3 mg/Levocetirizine Dihydrochloride 2 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxFluticasone Propionate 880 Mcg/10 ml Oral Suspension

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Adding

Radio 3

CheckboxFluticasone Propionate 3 mg/Fluconazole 15 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxFluticasone Propionate 50 Mcg/0.1 ml Poloxamer Nasal Spray

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Adding

Radio 3

CheckboxFluticasone Propionate 1%/Loratadine 2% Topical Gel

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Adding

Radio 3

CheckboxFurosemide 1 mg Capsules

Add

Adding

Radio 3

CheckboxFluticasone Propionate 3 mg/Itraconazole 50 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxFlurbiprofen 100 mg Slow Release Capsules

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Adding

Radio 3

CheckboxFluticasone Propionate 50 Mcg/0.1 ml/Vitamin A Palmitate Nasal Spray

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Adding

Radio 3

CheckboxFluticasone Propionate 1%/Ketotifen 0.05%/Lidocaine 5%/Imiquimod 2.5% Topical Gel

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Adding

Radio 3

CheckboxFurosemide 0.125% Topical Gel

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Adding

Radio 3

CheckboxFlurbiprofen 50 mg Slow Release Capsules

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Adding

Radio 3

CheckboxFurosemide 10 mg/0.1 ml Topical Gel (Vet)

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Adding

Radio 3

CheckboxFurosemide 10 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxFluticasone Propionate 3 mg/Azelastine HCl 350 Mcg/Montelukast 3 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxFurosemide 10 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Gabapentin 6%/Magnesium Chloride 5%/Lidocaine 2%/Prilocaine 2%/Amitriptyline HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxFluticasone Propionate 3 mg/Levocetirizine Dihydrochloride 2 mg/Montelukast 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxFluticasone Propionate 50 Mcg/0.1 ml Nasal Spray

Add

Adding

Radio 3

CheckboxFluticasone Propionate 440 Mcg/10 ml Oral Suspension

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Baclofen 2%/Cyclobenzaprine HCl 2%/Tetracaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxFlurbiprofen 5%/Tizanidine HCl 0.2%/Cyclobenzaprine HCl 2%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Amitriptyline HCl 2%/Cyclobenzaprine HCl 2% Topical Spray

Add

Adding

Radio 3

CheckboxFluoxetine 20% Topical Gel

Add

Adding

Radio 3

CheckboxFluoxetine 20 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Capsaicin 0.25% Topical Spray

Add

Adding

Radio 3

CheckboxFluocinonide 0.05% Topical Solution

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Cyclobenzaprine HCl 1%/Gabapentin 6%/Lidocaine 2%/Prilocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxFluocinonide 0.025% Topical Ointment

Add

Adding

Radio 3

CheckboxFluoxetine 5 mg Capsules

Add

Adding

Radio 3

CheckboxFluoxetine 10 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Amitriptyline HCl 1%/Gabapentin 6%/Lidocaine 2%/Prilocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Bupivacaine HCl 2%/DMSO Topical Spray

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Lidocaine 2%/Prilocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Cyclobenzaprine HCl 1%/Gabapentin 6%/Lidocaine 2%/Prilocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxFluoxetine 10 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxFlurbiprofen 5%/Camphor 0.5%/Menthol 0.5%/Capsaicin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxFluoxetine 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxFluocinonide 0.015% Topical Ointment

Add

Adding

Radio 3

CheckboxFluoxetine 1 mg/ml To 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxFlurbiprofen 10%/Cyclobenzaprine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxFlurbiprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxFluoxetine 40 mg/Gm Topical Lipoderm®

Add

Adding

Radio 3

CheckboxFluoxetine 10 mg/Gm Topical Cream

Add

Adding

Radio 3

CheckboxFluocinonide 0.01% Topical Lotion

Add

Adding

Radio 3

CheckboxFluocinolone Acetonide 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxFluocinolone Acetonide 0.015% Topical Cream

Add

Adding

Radio 3

CheckboxFluocinolone Acetonide 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxFluocinonide 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxFluocinonide 0.01% Topical Ointment

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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