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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

Circle for steps.

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

CheckboxEstriol 0.5 mg Capsules

Add

Adding

Radio 3

CheckboxEstradiol Valerate 0.01% Topical Solution

Add

Adding

Radio 3

CheckboxEstriol 0.1% Nasal Suspension

Add

Adding

Radio 3

CheckboxEstriol 0.2 mg/0.1 ml Topical Cream

Add

Adding

Radio 3

CheckboxEstriol 0.1% Vaginal Gel

Add

Adding

Radio 3

CheckboxEstriol 0.5 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxEstriol 0.2%/Vitamin A Palmitate 0.3%/Vitamin E Acetate 0.6% Topical Cream

Add

Adding

Radio 3

CheckboxEstriol 0.1%/Testosterone 0.1% Vaginal Gel

Add

Adding

Radio 3

CheckboxEstriol 0.1%/Lipoic Acid 3% Topical Cream

Add

Adding

Radio 3

CheckboxEstriol 0.1%/Palmitoyl Pentapeptide/Acetyl Hexapeptide/Biopeptide Under Eye Cream

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Adding

Radio 3

CheckboxEstriol 0.2%/Testosterone 0.2% VaginalÂ Gel

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Adding

Radio 3

CheckboxEstradiol Valerate 2 mg Capsules

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Adding

Radio 3

CheckboxEstradiol 9 Mcg/Estriol 0.5 mg Vaginal Suppository

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Adding

Radio 3

CheckboxEstradiol 10 Mcg Vaginal Suppository

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Adding

Radio 3

CheckboxEstriol 0.2% Vaginal Gel

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Adding

Radio 3

CheckboxEstriol 0.3% Topical Gel

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Adding

Radio 3

CheckboxEstriol 0.1% Topical/Vaginal Cream

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Adding

Radio 3

CheckboxEstradiol 5 Mcg Vaginal Suppository

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Adding

Radio 3

CheckboxEstriol 0.3%/Tretinoin 0.01% Topical Cream

Add

Adding

Radio 3

CheckboxEstriol 0.1%/Testosterone 0.1% Vaginal Cream

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Adding

Radio 3

CheckboxEstradiol Valerate 1 mg Capsules

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Adding

Radio 3

CheckboxEstradiol 0.01%/Betamethasone Dipropionate 0.05% Topical Ointment

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Adding

Radio 3

CheckboxEstradiol 0.5 mg/Progesterone 100 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.01%/Dehydroepiandrosterone 0.5%/Testosterone 0.05% VaginalÂ Gel

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg/0.1 ml Nasal Spray

Add

Adding

Radio 3

CheckboxEstradiol 0.2 mg/Progesterone 100 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.35 mg/Progesterone 100 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxEstradiol 0.03%/Testosterone 0.01% VaginalÂ Gel

Add

Adding

Radio 3

CheckboxEstradiol 0.5%/Progesterone 2% Topical Solution

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Adding

Radio 3

CheckboxErythromycin 125 mg/5 ml Oral Suspension

Add

Adding

Radio 3

CheckboxErythromycin 4%/Zinc Acetate 1.2% Topical Suspension

Add

Adding

Radio 3

CheckboxEstradiol 0.01%/Estriol 0.2% Topical Cream

Add

Adding

Radio 3

CheckboxErythromycin 200 mg Troche

Add

Adding

Radio 3

CheckboxEstradiol 0.5 mg Troche

Add

Adding

Radio 3

CheckboxEstradiol 0.6 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxErythromycin 250 mg/5 ml Oral Suspension (Flavored)

Add

Adding

Radio 3

CheckboxEstradiol 0.01% Vaginal Cream (Propylene Glycol Free)

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Adding

Radio 3

CheckboxErythromycin 250 mg Slow Release Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxErythromycin 500 mg/Nystatin 100,000 Units Suppository

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Adding

Radio 3

CheckboxErythromycin 4%/Zinc Acetate 1.2% Topical Gel

Add

Adding

Radio 3

CheckboxEstradiol 1 mg/0.1 ml Topical Cream

Add

Adding

Radio 3

CheckboxErythromycin 250 mg Suppository

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 2 mg Troche

Add

Adding

Radio 3

CheckboxErythromycin 2% Topical Ointment

Add

Adding

Radio 3

CheckboxErythromycin 2% Topical Solution

Add

Adding

Radio 3

CheckboxErythromycin 3%/Hydrocortisone 2% Topical Gel

Add

Adding

Radio 3

CheckboxErythromycin 4%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxErythromycin 1.5% Topical Lotion

Add

Adding

Radio 3

CheckboxErythromycin 2% Topical Cream

Add

Adding

Radio 3

CheckboxErythromycin 4%/Tretinoin 0.025% Topical Cream

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Adding

Radio 3

CheckboxErythromycin 2%/Ketoconazole 2%/Ciprofloxacin 1%/DMSO Nail Gel

Add

Adding

Radio 3

CheckboxErythromycin 4%/Hydrocortisone 1%/Tretinoin 0.01%/Ketoconazole 1% Topical Cream

Add

Adding

Radio 3

CheckboxErythromycin 3%/Tretinoin 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxErythromycin 1% Topical Ointment

Add

Adding

Radio 3

CheckboxErythromycin 2% Topical Lotion

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 2 mg/Caffeine 100 mg Suppository

Add

Adding

Radio 3

CheckboxErythromycin 2%/Fluocinolone Acetonide 0.025% Topical Ointment

Add

Adding

Radio 3

CheckboxErythromycin 3%/Tretinoin 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 1 mg/Caffeine 100 mg Capsules

Add

Adding

Radio 3

CheckboxErythromycin 2%/Clindamycin 1% Topical Suspension

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 0.6 mg/Belladonna Extract 16 mg Capsules

Add

Adding

Radio 3

CheckboxEphedrine Sulfate 7.5 mg/Atropine Sulfate 0.15 mg Troche

Add

Adding

Radio 3

CheckboxErgocalciferol 8000 U/ml Oral Drops

Add

Adding

Radio 3

CheckboxEpinephrine 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxEpinephrine 2.25% Nasal Spray

Add

Adding

Radio 3

CheckboxEnrofloxacin 200 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 0.6 mg/Belladonna Extract 16 mg/Phenobarbital 40 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxEpinephrine 0.22 mg/0.1 ml Oral Spray

Add

Adding

Radio 3

CheckboxEphedrine Sulfate 50 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 1 mg/Caffeine 100 mg/Riboflavin 200 mg Capsules

Add

Adding

Radio 3

CheckboxEnrofloxacin 2%/Ketoconazole 2%/Triamcinolone 0.25% Poloxamer Otic Gel (Vet)

Add

Adding

Radio 3

CheckboxEnrofloxacin 10 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxEnrofloxacin 10 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxEnrofloxacin 20 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxEphedrine Sulfate 5 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 1 mg/Caffeine 100 mg Suppository

Add

Adding

Radio 3

CheckboxEnrofloxacin 100 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxErgotamine Tartrate 0.36 mg/0.1 ml Oral Spray

Add

Adding

Radio 3

CheckboxEphedrine Sulfate 75 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxEdetate Disodium 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxEdetate Disodium 500 mg Suppository

Add

Adding

Radio 3

CheckboxEdetate Disodium 750 mg Suppository

Add

Adding

Radio 3

CheckboxEnrofloxacin 2%/Ketoconazole 2%/Triamcinolone 0.5% Poloxamer Otic Gel (Vet)

Add

Adding

Radio 3

CheckboxEGCG 50 mg Troche

Add

Adding

Radio 3

CheckboxEconazole Nitrate 250 mg Capsules

Add

Adding

Radio 3

CheckboxEdetate Disodium 0.25% Shampoo

Add

Adding

Radio 3

CheckboxEnalapril Maleate 7.5 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxEGCG 1%/Tea Tree Oil 1% Topical Cream

Add

Adding

Radio 3

CheckboxEGCG 1% Topical Cream

Add

Adding

Radio 3

CheckboxEconazole Nitrate 125 mg Capsules

Add

Adding

Radio 3

CheckboxEGCG 200 mg/Levocarnitine 10 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxEnalapril Maleate 0.5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxEnrofloxacin 0.5%/Ketoconazole 1%/Triamcinolone 0.1% Otic Ointment (Vet)

Add

Adding

Radio 3

CheckboxEnalapril 0.5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxEGCG 1%/Quercetin Dihydrate 1% Topical Gel

Add

Adding

Radio 3

CheckboxEnalapril Maleate 2.5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxEnalapril Maleate 10 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxEGCG 1%/Imiquimod 1% Topical Gel

Add

Adding

Radio 3

CheckboxEGCG 0.4% Nasal Spray

Add

Adding

Radio 3

CheckboxEGCG 1%/Tea Tree Oil 1%/Deoxy-D-Glucose Topical Cream

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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