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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

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Adding

Radio 3

CheckboxFluocinonide 0.1% Topical Gel

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Adding

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CheckboxFluocinonide 0.05% Topical Lotion

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CheckboxFluocinolone Acetonide 0.05% Topical Ointment

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CheckboxFluocinolone Acetonide 0.05% Topical Solution

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CheckboxFluocinolone Acetonide 0.05% Topical Gel

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CheckboxFluocinonide 0.1% Topical Solution

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Radio 3

CheckboxFluocinolone Acetonide 0.01%/Ketotifen 0.05% Topical Cream

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Radio 3

CheckboxFluocinolone Acetonide 0.01%/DMSO Otic Solution (Vet)

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CheckboxFluocinolone Acetonide 0.015% Topical Ointment

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Radio 3

CheckboxFluocinonide 0.1% Topical Ointment

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Radio 3

CheckboxFluocinolone Acetonide 0.01%/Hydroquinone 4%/Tretinoin 0.05% Topical Gel

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Radio 3

CheckboxFluocinonide 0.05% Oral Adhesive Paste

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Radio 3

CheckboxFlunisolide 0.025% Nasal Spray

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Radio 3

CheckboxFluconazole 2%/Ibuprofen 2%/Terbinafine HCl 2% Nail Solution

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CheckboxFluocinolone Acetonide 0.1% Topical Cream

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Radio 3

CheckboxFluconazole 50 mg/ml Oral Suspension

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CheckboxFluocinolone Acetonide 0.01% Shampoo

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Radio 3

CheckboxFluconazole 10 mg Capsules

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CheckboxFluconazole 100 mg/ml Oral Suspension (Vet)

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CheckboxFluocinolone Acetonide 0.01% Topical Cream

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Radio 3

CheckboxFlucytosine 15% Vaginal Cream

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Radio 3

CheckboxFlucytosine 50 mg/ml Oral Suspension

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Radio 3

CheckboxFluconazole 15 mg/Betamethasone 0.75 mg Capsules

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Radio 3

CheckboxFluocinolone Acetonide 0.1% Topical Ointment

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CheckboxFluocinolone Acetonide 0.01% Topical Lotion

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Radio 3

CheckboxFlucytosine 10 mg/ml Oral Suspension

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Adding

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CheckboxFluconazole 3%/Ibuprofen 2%/Itraconazole 1%/Terbinafine HCl 1% Nail Suspension

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Adding

Radio 3

CheckboxFluconazole 15 mg Capsules

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CheckboxFluconazole 10%/Ibuprofen 2% Topical Cream

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Radio 3

CheckboxFluconazole 75 mg Polyglycol Troche

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Adding

Radio 3

CheckboxFluconazole 2%/Ibuprofen 2%/Terbinafine HCl 2%/Tea Tree Oil/DMSO Nail Solution

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Adding

Radio 3

CheckboxFluocinolone Acetonide 0.01% Topical Ointment

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Radio 3

CheckboxEthinyl Estradiol 20 Mcg Capsules

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Radio 3

CheckboxFerrous Fumarate 200 mg/Ascorbic Acid 600 mg Capsules

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CheckboxEthinyl Estradiol 50 Mcg Capsules

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Radio 3

CheckboxFluconazole 0.2%/Acetic Acid 0.45% Vaginal Gel

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CheckboxFluconazole 1%/DMSO Topical Solution

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Adding

Radio 3

CheckboxFexofenadine HCl 180 mg Slow Release Capsules (Gluten Free)

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CheckboxFinasteride 0.25% Facial Cream

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CheckboxFamotidine 1 Gm/10 ml Oral Paste (Vet-Equine)

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CheckboxFentanyl 100 Mcg Troche

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Adding

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CheckboxEthinyl Estradiol 500 Mcg Capsules

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Adding

Radio 3

CheckboxFamotidine 2.5 mg/0.1 ml Topical Cream (Vet)

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Radio 3

CheckboxEthosuximide 200 mg Capsules

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Adding

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CheckboxFamotidine 5 mg/ml Oral Suspension (Vet)

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Radio 3

CheckboxFamotidine 40 mg/5 ml Oral Suspension (Gluten Free)

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Radio 3

CheckboxFinasteride 1.5 mg Capsules

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Radio 3

CheckboxFentanyl 200 Mcg Troche

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CheckboxFerrous Gluconate 6.475 mg/ml Oral Solution

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CheckboxFinasteride 0.25% Facial Topical Cream

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CheckboxFinasteride 1 mg/Biotin 1.2 mg Capsules

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CheckboxEthosuximide 250 mg/5 ml Oral Syrup (Flavored)

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CheckboxFentanyl 17 Mcg Troche

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CheckboxFerrous Fumarate 45 mg/0.6 ml Oral Drops

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CheckboxFexofenadine HCl 6 mg/ml Oral Suspension

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CheckboxEstriol/Estradiol [50%/50%] 0.25-2.5 mg/Gm Topical Gel

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Adding

Radio 3

CheckboxEstriol/Estradiol [50%/50%] 0.1-2.5 mg/Gm/Testosterone 0.25-10 mg/Gm Topical Cream

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CheckboxEstriol/Estradiol/Estrone [80%-10%-10%] 0.625-2.5 mg Slow Release Capsules

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Adding

Radio 3

CheckboxEstriol/Estradiol [80%-20%] 0.25 - 2.5 mg/Gm Topical Cream/Gel

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Adding

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CheckboxEstriol/Estradiol [80%-20%] 1 - 2.5 mg/Progesterone 100 - 200 mg Slow Release Capsules

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Adding

Radio 3

CheckboxEstriol/Estradiol [80%-20%] 0.1 - 0.6 mg/0.1 ml Topical Cream

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Adding

Radio 3

CheckboxEstriol/Estradiol/Estrone [80%-10%-10%] 0.625-2.5 mg/Progesterone 50-100 mg/Testosterone 0.125-2 mg Slow Release Capsules

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Radio 3

CheckboxEstriol/Estradiol [50%/50%] 0.1-2.5 mg/Gm/Progesterone 10-100 mg/Gm Topical Cream

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Radio 3

CheckboxEstriol/Estradiol [80%-20%] 0.5 - 1.25 mg Troche/Slow Release Capsules

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Adding

Radio 3

CheckboxEstriol/Estradiol/Estrone [80%-10%-10%] 0.625-2.5 mg/Progesterone 50-100 mg/Testosterone 0.125-2 mg Troche

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Radio 3

CheckboxEstriol/Estradiol [50%/50%] 0.05-0.5 mg/Gm/Testosterone 0.25-10 mg/Gm Topical Gel

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CheckboxEstriol/Estradiol [50%/50%] 0.25-1 mg Slow Release Capsules

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Radio 3

CheckboxEstriol/Estradiol [50%/50%] 0.25-1 mg/0.5-0.1 ml Sublingual Suspension

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Radio 3

CheckboxEstriol/Estradiol/Estrone [80%-10%-10%] 0.625-2.5 mg Troche

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Radio 3

CheckboxEstriol/Estradiol/Estrone [80%-10%-10%] 0.625-2.5 mg/ml Topical Cream

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Adding

Radio 3

CheckboxEstriol/Estradiol [50%/50%] 0.25-10 mg/Gm/Progesterone 10-125 mg/Gm/Testosterone 0.5-10 mg/Gm Topical Cream

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Radio 3

CheckboxEstriol/Estradiol/Estrone [80%-10%-10%] 0.625-2.5 mg Capsules

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Adding

Radio 3

CheckboxEstrone 0.01% Vaginal Cream

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Adding

Radio 3

CheckboxEstriol/Estradiol [80%-20%] 1.25 mg/ml - 5 mg/ml Topical Gelstriol/Estradiol [50%/50%] 0.5-1 mg/Progesterone 50-200 mg Troche

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Radio 3

CheckboxEstriol/Estradiol [50%/50%] 0.05-0.5 mg/Gm/Progesterone 5-50 mg/Gm Topical Gel

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Radio 3

CheckboxEstriol/Estradiol [80%-20%] 1 - 2.5 mg/Progesterone 100 - 200 mg Troche

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Radio 3

CheckboxEstriol 1 mg/Progesterone 30 mg Vaginal Suppository

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Radio 3

CheckboxEstriol 0.025% To 1% Topical/Vaginal Cream

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Radio 3

CheckboxEstriol 5 mg/ml Vaginal Cream

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Radio 3

CheckboxEstriol 1 mg Capsules

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Radio 3

CheckboxEstriol 2 mg/0.1 ml Topical Cream

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Radio 3

CheckboxEstriol/Estradiol [50%/50%] 0.1-0.5 mg/0.25-0.5 ml Topical Cream

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Adding

Radio 3

CheckboxEstriol 2 mg Capsules

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Adding

Radio 3

CheckboxEstriol 0.05% Vaginal Gel

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Adding

Radio 3

CheckboxEstriol 1 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxEstriol 1 mg Vaginal Suppository

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Adding

Radio 3

CheckboxEstriol 0.025%/Testosterone 0.025% Vaginal Gel

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Adding

Radio 3

CheckboxEstriol 0.5% Topical Cream

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Adding

Radio 3

CheckboxEstriol 0.005% Vaginal Gel

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Radio 3

CheckboxEstriol 1 mg/Mannose (D) 150 mg Capsules (Vet)

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Radio 3

CheckboxEstriol 0.05% Topical Cream

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Radio 3

CheckboxEstriol 1 mg/0.25 ml/Testosterone 1 mg/0.25 ml Vaginal Cream

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Radio 3

CheckboxEstriol 0.05% Vaginal Cream

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Radio 3

CheckboxEstriol 3 mg/ml Vaginal Cream

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Radio 3

CheckboxEstriol 0.5 mg/Testosterone 0.5 mg Vaginal Suppository

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Adding

Radio 3

CheckboxEstriol 0.5%/Testosterone 0.5% Vaginal Gel

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Adding

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CheckboxEstriol 0.01%/Coenzyme Q-10 1%/Lipoic Acid 3%/Ascorbic Acid 5%/Dmae/Palmitoyl Pentapeptide Topical Cream

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CheckboxEstriol 0.2% Topical Biopeptide Cream

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CheckboxEstriol 0.5 mg/ml Vaginal Gel

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Radio 3

CheckboxEstradiol 5 Mcg/Dehydroepiandrosterone 3 mg Vaginal Suppository

Directions:

QTY:

Refills

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2

3

4

5

6

7

8

9

10

xPrescriber's Signature:

Date

3

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Fill out the Pharmacy Name and Fax Number, then fax it to the Pharmacy.

Pharmacy Name

Pharmacy Fax Number

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