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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

CheckboxChlorhexidine Gluconate 0.5% Vaginal Gel

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 0.12%/Dyclonine HCl 1% Dental Rinse

Add

Adding

Radio 3

CheckboxChloramphenicol 250 mg Capsules

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 1.8%/Fluoride 0.25 mg Troche

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 1% Shampoo

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 0.25%/Lidocaine HCl 2% Oral Gel

Add

Adding

Radio 3

CheckboxChlorhexidine Diacetate 1% Topical Ointment (Vet)

Add

Adding

Radio 3

CheckboxChlorhexidine Gluconate 0.2% Oral Rinse

Add

Adding

Radio 3

CheckboxChloral Hydrate 100 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxCarbamazepine 200 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCarisoprodol 200 mg/Aspirin 325 mg/Codeine Phosphate 16 mg Capsules

Add

Adding

Radio 3

CheckboxCarbidopa 10 mg/Levodopa 100 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCarbidopa 25 mg/Levodopa 100 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCarbidopa 1.25 mg/ml/Levodopa 5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCarbamazepine 20 mg/ml Oral Suspension (Gluten Free)

Add

Adding

Radio 3

CheckboxCarbamazepine 100 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCelecoxib 2% Topical Cream

Add

Adding

Radio 3

CheckboxCarbidopa 2 mg/ml/Levodopa 20 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCarisoprodol 350 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCastor Oil 20%/Zinc Oxide 9.1% Topical Ointment

Add

Adding

Radio 3

CheckboxCarbidopa 50 mg/Levodopa 200 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxCarbamazepine 2%/Zinc Pyrithione 0.2%/Cyanocobalamin 0.07% Topical Gel

Add

Adding

Radio 3

CheckboxCelecoxib 1.25% Topical Cream

Add

Adding

Radio 3

CheckboxCarbamazepine 100 mg Troche

Add

Adding

Radio 3

CheckboxCelecoxib 8% Topical Cream

Add

Adding

Radio 3

CheckboxCefazolin 33.3 mg/ml Ophthalmic Solution

Add

Adding

Radio 3

CheckboxChloral Hydrate 1 Gm/Hydroxyzine HCl 25 mg Suppository

Add

Adding

Radio 3

CheckboxCarbidopa 25 mg/Levodopa 250 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCarbamazepine 200 mg Troche

Add

Adding

Radio 3

CheckboxCaptopril 25 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCantharidin 1%/Salicylic Acid 30% Topical Occlusaderm®

Add

Adding

Radio 3

CheckboxCapsaicin 4 Mcg/0.1 ml Nasal Spray

Add

Adding

Radio 3

CheckboxCapsaicin 0.03% Nasal Spray

Add

Adding

Radio 3

CheckboxCapsaicin 0.25 mg Troche

Add

Adding

Radio 3

CheckboxCapsaicin 0.01% Oral Rinse

Add

Adding

Radio 3

CheckboxCarbamazepine 2%/Ketoprofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxCaptopril 5 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxCaptopril 1 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxCamphor 6%/Methyl Salicylate 14%/Menthol 3% Topical Lotion

Add

Adding

Radio 3

CheckboxCarbamazepine 2%/Zinc Pyrithione 0.2%/Cyanocobalamin 0.07% Topical Cream

Add

Adding

Radio 3

CheckboxCapsicum Oleoresin 0.4% Topical Gel Cream

Add

Adding

Radio 3

CheckboxCaptopril 1 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCaptopril 5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCantharidin 1% Plus Topical Liquid

Add

Adding

Radio 3

CheckboxCaptopril 12.5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCapsaicin 0.025%/Methyl Salicylate 15%/Camphor 3.6% Topical Lotion

Add

Adding

Radio 3

CheckboxCamphor 12%/Menthol 2%/Methyl Salicylate 5% Nasal Ointment

Add

Adding

Radio 3

CheckboxCantharidin 1% Topical Liquid

Add

Adding

Radio 3

CheckboxCaptopril 50 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCamphor 3%/Menthol 1.25%/Methyl Salicylate 10% Topical Lotion

Add

Adding

Radio 3

CheckboxCalcium Gluconate 2.5% Topical Gel

Add

Adding

Radio 3

CheckboxCamphor 0.5%/Zinc Oxide 3% Topical Ointment

Add

Adding

Radio 3

CheckboxCamphor 1%/Phenol 2%/Boric Acid 2%/Zinc Oxide 5% Rectal Gel

Add

Adding

Radio 3

CheckboxCalcium L-5 Methyltetrahydrofolate 7.5 mg Capsules

Add

Adding

Radio 3

CheckboxCalcium L-5 Methyltetrahydrofolate 10 mg Capsules

Add

Adding

Radio 3

CheckboxCamphor 5%/Menthol 3% Compound Topical Ointment

Add

Adding

Radio 3

CheckboxCalcium L-5 Methyltetrahydrofolate 1 mg Capsules

Add

Adding

Radio 3

CheckboxCamphor 5%/Eucalyptus Oil 5%/Menthol 5% Topical Ointment

Add

Adding

Radio 3

CheckboxCalcium Phosphate Dibasic 6.66% Oral Suspension

Add

Adding

Radio 3

CheckboxCalcium Gluconate 5 Gm/30 ml Oral Suspension

Add

Adding

Radio 3

CheckboxCalcium L-5 Methyltetrahydrofolate 15 mg Capsules

Add

Adding

Radio 3

CheckboxCamphor 2%/Phenol 1%/Boric Acid 5% Compound Topical Ointment

Add

Adding

Radio 3

CheckboxCamphor 2%/Menthol 5% Topical Gel

Add

Adding

Radio 3

CheckboxCamphor 3% Topical Cream

Add

Adding

Radio 3

CheckboxCalcium Gluconate 134.4 mg/ml/Calcium Citrate 59.4 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCalcium L-5 Methyltetrahydrofolate 5 mg/ml/Methylcobalamin 2 mg/ml Sublingual Solution

Add

Adding

Radio 3

CheckboxCalcium L-5 Methyltetrahydrofolate 5 mg Capsules

Add

Adding

Radio 3

CheckboxCamphor 5%/Menthol 5% Compound Topical Ointment

Add

Adding

Radio 3

CheckboxCaffeine 5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCaffeine 0.005% Shampoo

Add

Adding

Radio 3

CheckboxCaffeine 5 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxCalcium Carbonate 33.3% Oral Suspension

Add

Adding

Radio 3

CheckboxCalcitriol 250 Ng/Gm Topical Cream

Add

Adding

Radio 3

CheckboxCalcium Chloride 100 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxCalcitriol 250 Ng/Gm Topical Ointment

Add

Adding

Radio 3

CheckboxCaffeine 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCaffeine 200 mg/Ephedrine HCl 25 mg Capsules

Add

Adding

Radio 3

CheckboxCalcium Glubionate 1.8 Gm/5 ml Oral Syrup (Vet)

Add

Adding

Radio 3

CheckboxCalcitriol 500 Ng/Gm Topical Ointment

Add

Adding

Radio 3

CheckboxCalcium Carbonate 10% Oral Suspension

Add

Adding

Radio 3

CheckboxCaffeine 100 mg/Promethazine HCl 50 mg/Dihydroergotamine Mesylate 5 mg Suppository

Add

Adding

Radio 3

CheckboxCalcium Acetate 10% Topical Gel

Add

Adding

Radio 3

CheckboxCaffeine Citrate 10 mg/ml Oral Solution (Gluten Free)

Add

Adding

Radio 3

CheckboxCalcium 66 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCaffeine 100 mg/Butalbital 60 mg/Ergotamine Tartrate 2 mg/Atropine Sulfate 0.25 mg Suppository

Add

Adding

Radio 3

CheckboxCaffeine 0.005% Scalp Solution

Add

Adding

Radio 3

CheckboxCalcipotriene 0.0015% Topical Cream

Add

Adding

Radio 3

CheckboxCaffeine 5% Topical Gel

Add

Adding

Radio 3

CheckboxCalcitriol 4 Ng/0.25 ml Oral Solution (Vet)

Add

Adding

Radio 3

CheckboxCalcitriol 20 Ng/0.2 ml Oral Solution (Vet)

Add

Adding

Radio 3

CheckboxButalbital 6 mg/ml Oral Elixir

Add

Adding

Radio 3

CheckboxButalbital 50 mg/Aspirin 325 mg/Caffeine 40 mg/Codeine Phosphate 30 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxButalbital 50 mg/Aspirin 325 mg/Caffeine 40 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxButalbital 200 mg Capsules

Add

Adding

Radio 3

CheckboxBuspirone HCl 10 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxBudesonide 10 mg Slow Release Acid Resistant Capsules

Add

Adding

Radio 3

CheckboxBudesonide 5 mg Slow Release Acid Resistant Capsules

Add

Adding

Radio 3

CheckboxBuprenorphine 0.5% Nasal Spray

Add

Adding

Radio 3

CheckboxBudesonide 2 mg/30 ml Retention Enema

Add

Adding

Radio 3

CheckboxBuprenorphine 0.4 mg Troche

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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