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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

CheckboxClindamycin 2%/Triamcinolone Acetonide 0.1% Nasal Gel

Add

Adding

Radio 3

CheckboxClindamycin 1%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxClindamycin 1%/Lidocaine 1%/Naltrexone HCl 1%/Clobetasol Propionate 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxClindamycin 150 mg/Tobramycin 125 mg/Betamethasone 0.5 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxClindamycin 1 mg/Gm/Gentamicin 1 mg/Gm/Polymyxin B 2,000 U/Gm Topical Gel

Add

Adding

Radio 3

CheckboxClindamycin 100 mg/Vitamin E 200 IU Vaginal Suppository

Add

Adding

Radio 3

CheckboxClindamycin 1 mg/ml/Gentamicin 1 mg/ml/Polymyxin B 2,000 U/ml Bladder Irrigation Solution

Add

Adding

Radio 3

CheckboxCiprofloxacin 2%/Itraconazole 2% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxCitric Acid 39.5% Dental Gel

Add

Adding

Radio 3

CheckboxCiprofloxacin 90 mg/Mupirocin 20 mg/Fluconazole 15 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxCisapride 10 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxCitric Acid 20% Shampoo

Add

Adding

Radio 3

CheckboxCiprofloxacin 90 mg/Fluconazole 15 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxCiprofloxacin 90 mg/Clotrimazole 10 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxCisapride 10 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxCiprofloxacin 90 mg/Fluconazole 15 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxCiprofloxacin 90 mg/Mupirocin 20 mg/Clotrimazole 10 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxCiprofloxacin 250 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCiprofloxacin 90 mg Capsules

Add

Adding

Radio 3

CheckboxCisapride 5 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxCiprofloxacin 2%/Ketoconazole 1% Otic Gel

Add

Adding

Radio 3

CheckboxClarithromycin 100 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxCitric Acid 4% Dental Gel

Add

Adding

Radio 3

CheckboxCiprofloxacin 50 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxCisapride 1 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxCiprofloxacin 2% Vaginal Gel

Add

Adding

Radio 3

CheckboxCiprofloxacin 2%/Ketoconazole 2% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxCiprofloxacin 90 mg/Clotrimazole 10 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxCisapride 2.5 mg/0.1 ml Topical Cream (Vet)

Add

Adding

Radio 3

CheckboxCimetidine 5%/Lidocaine 2%/Zinc Oxide 10%/Quercetin 1% Topical Gel

Add

Adding

Radio 3

CheckboxCiclopirox 8%/Itraconazole 3%/Ibuprofen 2%/Fluconazole 3%/Terbinafine HCl 1% Topical Cream

Add

Adding

Radio 3

CheckboxCiprofloxacin 0.3%/Hydrocortisone 1% Otic Suspension

Add

Adding

Radio 3

CheckboxCimetidine 10%/Salicylic Acid 3%/Acyclovir 2%/Naltrexone HCl 1%/Egcg 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxCiprofloxacin 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxCimetidine 10%/Tea Tree Oil 2%/Egcg 1%/Deoxy-D-Glucose Topical Gel

Add

Adding

Radio 3

CheckboxCimetidine 400 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCimetidine 60 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCimetidine 5% Topical Gel

Add

Adding

Radio 3

CheckboxCimetidine 10% Topical Gel

Add

Adding

Radio 3

CheckboxCiclopirox 8%/Urea 40% Nail Gel

Add

Adding

Radio 3

CheckboxCiclopirox 8%/Fluconazole 1%/Terbinafine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxCimetidine 15%/Salicylic Acid 3%/Acyclovir 2%/Naltrexone HCl 1%/Egcg 0.2% Topical Cream

Add

Adding

Radio 3

CheckboxCimetidine 200 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCimetidine 10%/Acyclovir 5%/Egcg 1% Vaginal Gel

Add

Adding

Radio 3

CheckboxCimetidine 300 mg/5 ml Oral Syrup

Add

Adding

Radio 3

CheckboxCiclopirox 8%/Itraconazole 3%/Ibuprofen 2%/Fluconazole 3%/Terbinafine HCl 1%/DMSO Topical Suspension

Add

Adding

Radio 3

CheckboxCimetidine 300 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxChrysin 10% Topical Cream

Add

Adding

Radio 3

CheckboxCholestyramine 5%/Zinc Oxide 5% Topical Gel

Add

Adding

Radio 3

CheckboxCiclopirox 1%/Clobetasol Propionate 0.05% Topical Shampoo

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 9 mg/Phenylephrine HCl 21 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxChrysin 5%/Testosterone 5% Topical Cream

Add

Adding

Radio 3

CheckboxCholestyramine 5%/Miconazole Nitrate 0.5%/Mupirocin 0.5% Topical

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 8 mg/Pseudoephedrine HCl 60 mg/Guaifenesin 200 mg/Dextromethorphan HBr 30 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxCholestyramine 5% Topical Ointment

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 8 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxCholestyramine 5%/Mupirocin 0.5%/Miconazole Nitrate 0.5% Topical Ointment

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 4 mg/Pseudoephedrine HCl 30 mg/Guaifenesin 100 mg/Dextromethorphan HBr 10 mg Capsules

Add

Adding

Radio 3

CheckboxCholestyramine 400 mg Capsules

Add

Adding

Radio 3

CheckboxCholestyramine 10% Topical Ointment

Add

Adding

Radio 3

CheckboxCholesterol 250 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 12 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxCiclopirox 0.77%/Terbinafine HCl 1%/Clotrimazole 1%/Betamethasone Dipropionate 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 4 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 4 mg Suppository

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 8 mg/Pseudoephedrine HCl 60 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 4 mg/Pseudoephedrine HCl 60 mg/Acetaminophen 650 mg Slow Release Capsules 0

Add

Adding

Radio 3

CheckboxChloroxylenol 0.5%/Sulfur 2%/Salicylic Acid 2% Shampoo (Vet)

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 0.4 mg/ml/Pseudoephedrine HCl 6 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 4% Body Wash

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 4 mg/Pseudoephedrine HCl 30 mg Capsules

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 1%/Sodium Fluoride 1% Oral Gel

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 4% Shampoo (Versabase®) (Vet)

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 1 mg/ml/Dextromethorphan HBr 3 mg/ml/Phenylephrine HCl 3.5 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 2 mg/Pseudoephedrine HCl 30 mg/Guaifenesin 100 mg Suppository

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 4% Skin Cleanser

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 2% Topical Solution (Vet)

Add

Adding

Radio 3

CheckboxChloroxylenol 1 mg/ml/Pramoxine HCl 5 mg/ml/Zinc Acetate 1 mg/ml Otic Solution

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 2 mg Suppository

Add

Adding

Radio 3

CheckboxChloroxylenol 0.1%/Hydrocortisone 1%/Pramoxine HCl 1% Otic Solution

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 2.5 mg/Prednisolone 5 mg Capsules (Vet)

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 2 mg/5 ml Oral Syrup

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 2 mg/0.1 ml Topical Cream (Vet)

Add

Adding

Radio 3

CheckboxChloroquine Phosphate 16.7 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxChlorpheniramine Maleate 0.8 mg/ml/Pseudoephedrine HCl 6 mg/ml/Dextromethorphan HBr 6 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxChloroquine Phosphate 100 mg/5 ml Oral Suspension

Add

Adding

Radio 3

CheckboxChlorobutanol 5%/Eugenol 8.9% Compound Dry Socket Paste

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 0.2%/Fluoride 0.3% Mouthwash

Add

Adding

Radio 3

CheckboxChloramphenicol 500 mg/Gm Oral Paste (Vet)

Add

Adding

Radio 3

CheckboxChloral Hydrate 25 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 0.5% Otic Cleanser (Vet)

Add

Adding

Radio 3

CheckboxChloral Hydrate 500 mg Capsules

Add

Adding

Radio 3

CheckboxChloramphenicol 0.5% Otic Solution

Add

Adding

Radio 3

CheckboxChlorhexidine Diacetate 0.2% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxChloramphenicol 1% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxChloramphenicol 0.42%/Prednisolone 0.17%/Tetracaine 0.42% Otic Solution (Vet)

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 0.1%/Betamethasone Dipropionate 0.05% Oral Gel

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 0.5% Topical Rinse

Add

Adding

Radio 3

CheckboxChloral Hydrate 500 mg Suppository

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 0.12% Oral Gel

Directions:

QTY:

Refills

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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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Thank you! Your submission has been received!

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