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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

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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% Vaginal 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

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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)

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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)

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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

Add

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

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