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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

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

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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

CheckboxChloral Hydrate 250 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxClonidine HCl 2.2 mg/mL/Gabapentin 60 mg/mL/Ketamine HCl 115 mg/mL/Lidocaine 20 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar 5%/Zinc Oxide 5% Topical Ointment

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 0.2 mg/mL/Deoxy D Glucose 1 mg/mL/Lidocaine HCl 10 mg/mL/Nystatin 1.9 mg/mL/Tetracycline HCl 12 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxClopidogrel 5 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxCinacalcet 5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCoal Tar 5%/Urea 2% Topical Gel

Add

Adding

Radio 3

CheckboxCiprofloxacin HCl 500 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxClopidogrel Bisulfate 0.5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2%/Gabapentin 10%/Ketamine 10% Ketoprofen 10%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar 1%/Zinc Oxide 25% Topical Paste

Add

Adding

Radio 3

CheckboxChlorothiazide 40 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxChlorpromazine HCl 25 mg/10 mL Rectal Enema

Add

Adding

Radio 3

CheckboxChloramphenicol 1% Topical Ointment

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.5 mg/g/Dyclonine HCl 10 mg/g Oral Paste

Add

Adding

Radio 3

CheckboxChlorpromazine HCl 25 mg/0.5 mL Topical Gel

Add

Adding

Radio 3

CheckboxCromolyn Sodium 10 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxCyclosporine 10 mg/g Oral Paste

Add

Adding

Radio 3

CheckboxClonazepam 0.25 mg Troches

Add

Adding

Radio 3

CheckboxChloral Hydrate 100 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxChlorpromazine HCl 25 mg/0.25 mL Nasal Spray

Add

Adding

Radio 3

CheckboxClonazepam 1 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxCoenzyme Q10 100 mg/mL Sublingual Solution

Add

Adding

Radio 3

CheckboxCiprofloxacin 1%/Dexamethasone 0.1% Otic Solution

Add

Adding

Radio 3

CheckboxChloroquine Phosphate 15 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCevimeline HCl 15 mg Capsules

Add

Adding

Radio 3

CheckboxCodeine Phosphate 3 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxClonidine HCl 2 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxCetirizine Dihydrochloride 10 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.5 mg/mL/Pyrithione Zinc 2 mg/mL Shampoo

Add

Adding

Radio 3

CheckboxCitric Acid 3% Oral Solution

Add

Adding

Radio 3

CheckboxCoal Tar Solution 2%/Salicylic Acid 6% Scalp Solution

Add

Adding

Radio 3

CheckboxClioquinol 30 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxCyanocobalamin 1 mg/mL Nasal Spray

Add

Adding

Radio 3

CheckboxCoal Tar Solution 5%/Salicylic Acid 10% Topical Suspension

Add

Adding

Radio 3

CheckboxClonidine HCl 10 mcg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 10 mg/Lidocaine 100 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxCetirizine Dihydrochloride 4 mg/0.2 mL Nasal Spray

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 10 mg/Naproxen 500 mg Rectal Suppositories

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Adding

Radio 3

CheckboxCoumarin 100 mg/g Topical Ointment

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Adding

Radio 3

CheckboxCoenzyme Q10 150 mg Capsules

Add

Adding

Radio 3

CheckboxCimetidine 100 mg/g/Deoxyglucose 2.5 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxCitric Acid 10% Oral Solution

Add

Adding

Radio 3

CheckboxCoenzyme Q10 0.5%/Retinoic Acid 0.5% Topical Ointment

Add

Adding

Radio 3

CheckboxCoal Tar Solution 5%/Salicylic Acid 5%/Triamcinolone Acetonide 0.16%/Urea 10% Topical Solution

Add

Adding

Radio 3

CheckboxCurcumin 0.5% Topical Ointment

Add

Adding

Radio 3

CheckboxClobetasol Propionate 1 mg/mL/Cyclosporine 20 mg/mL/Ketoprofen 25 mg/mL Nail Solution

Add

Adding

Radio 3

CheckboxClotrimazole 30 mg/mL/Miconazole 30 mg/mL Topical Solution

Add

Adding

Radio 3

CheckboxCamphor 20% Topical Stick

Add

Adding

Radio 3

CheckboxCapsaicin 0.75 mg/mL/Ketoprofen 50 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxCapsicum 5% Topical Ointment

Add

Adding

Radio 3

CheckboxCapsaicin 0.025%/Doxepin 3.3% Topical Cream

Add

Adding

Radio 3

CheckboxCalcitriol 100 ng/mL Oral Solution

Add

Adding

Radio 3

CheckboxCamphor 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxCapsaicin 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxCaffeine 25 mg/g/Meloxicam 7.5 mg/g/Promethazine 12.5 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxCarnitine 400 mg/mL/Ubidecarenone 10 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxCefepime HCl 10 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxCaffeine Citrate 65 mg/Ketoprofen 25 mg/Riboflavin 100 mg Capsules

Add

Adding

Radio 3

CheckboxCarbamazepine 10 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxCapsaicin 0.5 mg/mL/Ketamine HCl 20 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxCarbamazepine 50 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxCefuroxime Axetil 10 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxCarvedilol 5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCefazolin Sodium100 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxCefazolin Sodium 3.5 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxCarbamazepine 100 mg Rectal Suppositories

Add

Adding

Radio 3

CheckboxCarbamazepine 30 mg/g Topical Ointment

Add

Adding

Radio 3

CheckboxCapsaicin 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxCapsaicin 7.5 mg/mL/Ketamine HCl 20 mg/mL/Ketoprofen 100 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxLevocarnitine 300 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxCapsicum Oleoresin 0.3%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxCarbamazepine 25 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCapsaicin 0.05% Topical Stick

Add

Adding

Radio 3

CheckboxCamphor 2%/Lactic Acid 16.7%/Salicylic Acid 16.7%/Castor Oil Topical Solution

Add

Adding

Radio 3

CheckboxCaffeine 2.5% Nasal Spray

Add

Adding

Radio 3

CheckboxCaptopril 0.1%/Clobetasol 0.2%/Diphenhydramine 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxCarprofen 2.5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCelecoxib 10 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCapsicum Oleoresin 1.5% Topical Ointment

Add

Adding

Radio 3

CheckboxCapsaicin 0.1%/Menthol 2%/Methyl Salicylate 5%/Piroxicam 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxCarisoprodol 100 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxCarbidopa 1.25 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCamphor 0.3%/Menthol 0.3%/Phenol 0.3% Topical Gel

Add

Adding

Radio 3

CheckboxCaptopril 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxCapsicum 0.32%/Methyl Salicylate 25%/Menthol 2% Topical Cream

Add

Adding

Radio 3

CheckboxCapsaicin 0.025%/Menthol 10%/Methyl Salicylate 25% Topical Stick

Add

Adding

Radio 3

CheckboxCapsicum 100 mg/mL Topical Solution

Add

Adding

Radio 3

CheckboxCarisoprodol 200 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxCaptopril 1 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxCarvedilol 0.625 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCarvedilol 1.25 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxCaffeine 150 mg/Indomethacin 50 mg/Prochlorperazine Maleate 8 mg Suppositories

Add

Adding

Radio 3

CheckboxBelladonna Extract 10 mg/Caffeine Citrate 100 mg/Ergotamine Tartrate 1 mg/Acetaminophen 250 mg Capsules

Add

Adding

Radio 3

CheckboxBrompheniramine Maleate 2 mg/5 mL Oral Syrup

Add

Adding

Radio 3

CheckboxBenzocaine 2%/Camphor 9%/Phenol 3%/Tannic Acid 6% Topical Ointment

Add

Adding

Radio 3

CheckboxBenztropine Mesylate 1 mg/Dexamethasone 10 mg/Diphenhydramine HCl 25 mg/Haloperidol 1 mg/Lorazepam 1 mg/Metoclopramide HCl 40 mg Suppositories

Add

Adding

Radio 3

CheckboxBudesonide 3 mg Capsules

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 0.5%/Econazole Nitrate 1% Topical Lotion

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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