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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

CheckboxCoal Tar Topical Solution 6.25%/Aloe Vera 0.5% Topical Gel

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 12%/Sulfur 4%/Salicylic Acid 2% Topical Ointment

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 10%/Salicylic Acid 3%/Triamcinolone 0.1% Topical Gel

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 6%/Salicylic Acid 6%/Shea Butter Topical Cream

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 8% Topical Cream

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 8% Topical Ointment

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 10% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10%/Salicylic Acid 2% Scalp Lotion

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Anthralin 1% Topical Cream

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 10% Topical Oil

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Salicylic Acid 3%/Fluocinonide 0.05% Topical Lotion

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 5% Topical Cream

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Salicylic Acid 3% Pearlescent Topical Cream

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 2% Topical Oil

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Adding

Radio 3

CheckboxClotrimazole 100 mg Suppository

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 3%/Hydrocortisone 0.5% Topical Lotion

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Hydrocortisone 1% Topical Lotion

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 2%/Hydrocortisone 1%/Iodoquinol 1% Topical Cream

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Adding

Radio 3

CheckboxClotrimazole 2%/Mupirocin 1%/Betamethasone Acetate 0.025% Topical Lanolin Ointment

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 2%/Miconazole 2%/Selenium Sulfide 2%/Desonide 0.05% Shampoo

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 3%/Clioquinol 1%/Hydrocortisone 0.5% Topical Lotion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 4%/Salicylic Acid 3%/Sulfur 3% Topical Ointment

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Ibuprofen 2%/Tea Tree Oil 1% Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 3%/Clioquinol 1%/Hydrocortisone 1% Topical Lotion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 2.5%/Salicylic Acid 2%/Sulfur 2% Shampoo

Add

Adding

Radio 3

CheckboxClotrimazole 1%/Tea Tree Oil 54%/Undecylenic Acid 5%/Urea 5% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 2% Shampoo

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Adding

Radio 3

CheckboxCoal Tar Topical Solution 48.5%/Benzocaine 2%/Salicylic Acid 1% Topical Solution

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Adding

Radio 3

CheckboxClotrimazole 1%/Hydrocortisone 1% Otic Solution

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Urea 10% Compound Nail Solution

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10%/Betamethasone Dipropionate 0.025% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10%/Betamethasone Dipropionate 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Ibuprofen 2%/Tea Tree Oil 5% Topical Cream

Add

Adding

Radio 3

CheckboxClotrimazole 10 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxClotrimazole 10 mg Capsules

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 2%/Miconazole 2%/Selenium Sulfide 2%/Triamcinolone 0.1% Shampoo

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 3% Soapless Shampoo

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Ibuprofen 2%/Bacitracin 500 U/Gm/Deoxy-D-Glucose 0.2% Topical Ointment

Add

Adding

Radio 3

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

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Ibuprofen 2%/Tea Tree Oil 1% Topical Cream

Add

Adding

Radio 3

CheckboxClotrimazole 1% Oral Rinse

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Adding

Radio 3

CheckboxClonidine HCl 6.25 mcg Troche

Add

Adding

Radio 3

CheckboxClotrimazole 0.1%/Triamcinolone 0.025%/Urea 20% Topical Cream

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Adding

Radio 3

CheckboxClonidine HCl 0.1 mg/ml Oral Solution

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Adding

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CheckboxClonazepam 1 mg/ml Sublingual Drops

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Adding

Radio 3

CheckboxClotrimazole 1%/Gentamicin 0.3% Otic Solution

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Adding

Radio 3

CheckboxClomipramine HCl 5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxClomipramine HCl 5 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxClonidine HCl 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxClonidine HCl 0.1 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxClonidine HCl 0.2 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxClonidine HCl 0.1 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxClonazepam 0.1 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxClotrimazole 1%/Ciprofloxacin 0.3% Otic Solution

Add

Adding

Radio 3

CheckboxClomipramine HCl 50 mg/ml Nasal Solution

Add

Adding

Radio 3

CheckboxClotrimazole 1%/Ciprofloxacin 0.3%/Dexamethasone 0.1% Otic Solution

Add

Adding

Radio 3

CheckboxClomipramine HCl 5 mg/ml Oral Solution (Vet)

Add

Adding

Radio 3

CheckboxClonazepam 0.5 mg Troche

Add

Adding

Radio 3

CheckboxClomipramine HCl 5 mg/0.1 ml Topical Cream (Vet)

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Adding

Radio 3

CheckboxClotrimazole 1%/Gentamicin 0.3%/Betamethasone Valerate 0.12% Otic Gel (Vet)

Add

Adding

Radio 3

CheckboxClotrimazole 1 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxClotrimazole 1% Oral Adhesive Paste

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Adding

Radio 3

CheckboxClonidine HCl 20 mcg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxClotrimazole 1%/DMSO 10% Topical Solution

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Adding

Radio 3

CheckboxClobetasol Propionate 0.05%/Zinc Pyrithione 0.2% Topical Foam

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Adding

Radio 3

CheckboxClomiphene Citrate 5% Topical Cream

Add

Adding

Radio 3

CheckboxClomiphene Citrate 2.5% Topical Gel

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Adding

Radio 3

CheckboxClomiphene Citrate 12.5 mg/Zinc Gluconate 7 mg/Anastrozole 0.1 mg Capsules

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Adding

Radio 3

CheckboxClomiphene Citrate 2.5%/Testosterone 2.5% Topical Gel

Add

Adding

Radio 3

CheckboxClomiphene Citrate 5%/Testosterone 5% Topical Cream

Add

Adding

Radio 3

CheckboxClomiphene Citrate 2.5%/Testosterone 2.5% Topical Cream

Add

Adding

Radio 3

CheckboxClindamycin 200 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05% Topical/Vaginal Gel

Add

Adding

Radio 3

CheckboxClomiphene Citrate 12.5 mg/0.2 ml Sublingual Drops

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05%/Lidocaine Hydrochloride 1% Oral Gel

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05% Oral Rinse

Add

Adding

Radio 3

CheckboxClobetasol Propionate 8% Topical Nail Gel

Add

Adding

Radio 3

CheckboxClioquinol 3%/Hydrocortisone 1%/Pramoxine HCl 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxClomiphene Citrate 12.5 mg/Testosterone 12.5 mg/0.2 ml Sublingual Drops

Add

Adding

Radio 3

CheckboxClomiphene Citrate 5% Topical Solution

Add

Adding

Radio 3

CheckboxClobetasol Propionate 0.05% Topical Foam

Add

Adding

Radio 3

CheckboxClomiphene Citrate 25 mg Capsules

Add

Adding

Radio 3

CheckboxClomiphene Citrate 5%/Testosterone 5% Topical Gel

Add

Adding

Radio 3

CheckboxClomiphene Citrate 2.5% Topical Solution

Add

Adding

Radio 3

CheckboxClioquinol 3%/Hydrocortisone 1% Topical Ointment

Add

Adding

Radio 3

CheckboxClomiphene Citrate 2.5% Topical Cream

Add

Adding

Radio 3

CheckboxClioquinol 1%/Hydrocortisone 1% Otic Suspension

Add

Adding

Radio 3

CheckboxClioquinol 3%/Hydrocortisone 1% Topical Cream

Add

Adding

Radio 3

CheckboxClindamycin 150 mg Suppository

Add

Adding

Radio 3

CheckboxClindamycin 150 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxClindamycin 1%/Tretinoin 0.025% Topical Cream

Add

Adding

Radio 3

CheckboxClindamycin 1%/Betamethasone Valerate 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxClindamycin 1% Nasal Spray

Add

Adding

Radio 3

CheckboxClindamycin 150 mg/Levofloxacin 100 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxClindamycin 50 mg Capsules

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Adding

Radio 3

CheckboxClindamycin 30 mg/0.1 ml Topical Cream (Vet)

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Adding

Radio 3

CheckboxClindamycin 150 mg/Itraconazole 40 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxClindamycin 30 mg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxClindamycin 3%/Doxycycline 1% Topical Ointment

Add

Adding

Radio 3

CheckboxClindamycin 30 mg Capsules

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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