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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

CheckboxBuprenorphine 0.3 mg/ml Sublingual Solution (Vet)

Add

Adding

Radio 3

CheckboxBuprenorphine 0.43 mg Troche

Add

Adding

Radio 3

CheckboxBupivacaine 7.5%/Prilocaine 30% Topical Cream

Add

Adding

Radio 3

CheckboxBuprenorphine 2 mg/ml Sublingual Drops

Add

Adding

Radio 3

CheckboxBuspirone HCl 1.25 mg/0.2 ml Topical Cream (Vet)

Add

Adding

Radio 3

CheckboxBudesonide 1 mg/30 ml Retention Enema

Add

Adding

Radio 3

CheckboxBupropion HCl 30 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxBudesonide 4 mg Suppository

Add

Adding

Radio 3

CheckboxBuprenorphine 0.3% Nasal Spray

Add

Adding

Radio 3

CheckboxBuspirone HCl 5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxBuspirone HCl 2.5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxBupivacaine HCl 4% Rectal Gel

Add

Adding

Radio 3

CheckboxBuprenorphine 4 mg Rapid Dissolve Tablet

Add

Adding

Radio 3

CheckboxBuprenorphine 0.6 mg/ml Sublingual Solution

Add

Adding

Radio 3

CheckboxBuprenorphine 0.3 mg/0.1 ml Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxBuspirone HCl 5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxBudesonide 2 mg/10 ml Oral Suspension

Add

Adding

Radio 3

CheckboxBudesonide 1 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxBoric Acid 600 mg Vaginal Capsules

Add

Adding

Radio 3

CheckboxBudesonide 1 mg/10 ml Oral Slurry

Add

Adding

Radio 3

CheckboxBrompheniramine Maleate 0.4 mg/ml/Dextromethorphan Hydrobromide 1 mg/ml/Phenylephrine HCl 1 mg/ml/Guaifenesin 10 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxBoric Acid 30% Vaginal Gel

Add

Adding

Radio 3

CheckboxBoric Acid 4% Otic Solution

Add

Adding

Radio 3

CheckboxBudesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxBrimonidine Tartrate 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxBoric Acid 10% Ointment

Add

Adding

Radio 3

CheckboxBoric Acid 30%/Edetate Disodium 0.5% Vaginal Gel

Add

Adding

Radio 3

CheckboxBudesonide 0.05% Topical Foam

Add

Adding

Radio 3

CheckboxBrompheniramine Maleate 0.4 mg/ml/Phenylephrine HCl 1 mg/ml/Guaifenesin 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxBrompheniramine Maleate 12 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxBromocriptine Mesylate 5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxBudesonide 1 mg Troche

Add

Adding

Radio 3

CheckboxBrompheniramine Maleate 8 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxBrompheniramine Maleate 4 mg/Pseudoephedrine HCl 60 mg/Guaifenesin 300 mg Capsules

Add

Adding

Radio 3

CheckboxBoric Acid 750 mg/Chloramphenicol 750 mg/Hydrocortisone 10 mg Otic Insufflation Powder

Add

Adding

Radio 3

CheckboxBrompheniramine Maleate 8 mg/Pseudoephedrine HCl 120 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxBudesonide 1 mg/5 ml Oral Slurry

Add

Adding

Radio 3

CheckboxBoric Acid 2%/Phenol 1.89% (W/W)/Zinc Oxide 15% Topical Powder (Vet)

Add

Adding

Radio 3

CheckboxBoric Acid 600 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxBromocriptine Mesylate 2.5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxBoric Acid 30% Vaginal

Add

Adding

Radio 3

CheckboxBudesonide 1 mg/0.1 ml Topical Cream (Vet)

Add

Adding

Radio 3

CheckboxBismuth Citrate 410 mg Capsules

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.012%/Mupirocin 0.15% Topical Gel

Add

Adding

Radio 3

CheckboxBoric Acid 2.7% Alcoholic Otic Solution (Vet)

Add

Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.064%/Salicylic Acid 2% Topical Lotion

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.12% Scalp Solution

Add

Adding

Radio 3

CheckboxBismuth Citrate 4.1% Oral Suspension

Add

Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.05%/Urea 40%/Ammonium Lactate 7% Topical Cream

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.008%/Mupirocin 0.15% Topical Cream

Add

Adding

Radio 3

CheckboxBoric Acid 1%/Menthol 3% Compound Topical Ointment

Add

Adding

Radio 3

CheckboxBismuth Citrate 205 mg Capsules

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.008%/Mupirocin 0.15% Topical Gel

Add

Adding

Radio 3

CheckboxBismuth/Potassium Citrate Oral Solution

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.12%/Lidocaine HCl 2% Topical Spray

Add

Adding

Radio 3

CheckboxBiotin 200 mg Capsules

Add

Adding

Radio 3

CheckboxBetamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxBiotin 5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxBoric Acid 2.5%/Salicylic Acid 1%/Sulfur 1%/Camphor 0.333% Topical Lotion

Add

Adding

Radio 3

CheckboxBiotin 0.2% Scalp Spray

Add

Adding

Radio 3

CheckboxBismuth Ammonium Citrate Oral Solution

Add

Adding

Radio 3

CheckboxBethanechol Chloride 1 mg/ml To 5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxBiotin 0.2% Scalp Oil

Add

Adding

Radio 3

CheckboxBoric Acid 1%/Hydroxyquinoline Sulfate 0.026% Vaginal Jelly

Add

Adding

Radio 3

CheckboxBiotin 0.2% Topical Lotion

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.1% Topical Foam

Add

Adding

Radio 3

CheckboxBiotin 100 mg/Ketoconazole 100 mg/Atropine Sulfate 2.5 mg Suppository

Add

Adding

Radio 3

CheckboxBenzyl Benzoate 25% Topical Lotion

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Sulfur 5% Topical Lotion

Add

Adding

Radio 3

CheckboxBetahistine Dihydrochloride 4 mg Capsules

Add

Adding

Radio 3

CheckboxBetahistine Dihydrochloride 8 mg Capsules

Add

Adding

Radio 3

CheckboxBetamethasone 0.025% Dental Rinse

Add

Adding

Radio 3

CheckboxBenzyl Alcohol 5% Topical Gel

Add

Adding

Radio 3

CheckboxBenzyl Alcohol 20% Topical Gel

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 14%/Zinc Oxide 72% Topical Paste

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 20% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone 0.042% Nasal Spray

Add

Adding

Radio 3

CheckboxBetamethasone 0.05%/Salicylic Acid 3% Topical Ointment

Add

Adding

Radio 3

CheckboxBetamethasone 0.1% Nasal Solution

Add

Adding

Radio 3

CheckboxBetahistine Dihydrochloride 12 mg Capsules

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 20% Topical Cream

Add

Adding

Radio 3

CheckboxBenzyl Alcohol 5%/Tea Tree Oil 10%/Lavender Oil Topical Lotion

Add

Adding

Radio 3

CheckboxBetamethasone 0.05%/Clotrimazole 1% Topical Cream

Add

Adding

Radio 3

CheckboxBeta Glucan 0.05%/Sodium Hyaluronate 1.2% Topical Solution

Add

Adding

Radio 3

CheckboxBetahistine Dihydrochloride 16 mg Capsules

Add

Adding

Radio 3

CheckboxBetamethasone 0.1%/Lidocaine 0.2%/Aloe Vera 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone 0.6 mg/5 ml Oral Syrup

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Clindamycin 1% Clear Topical Gel

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Biotin 0.1%/Niacinamide 2% Topical Cream

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 7%/Niacinamide 2%/Biotin 0.1% Facial Gel

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Clindamycin 2% Topical Cream

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Erythromycin 3% Topical Cream

Add

Adding

Radio 3

CheckboxBenzoin Tincture 8% Topical Ointment

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Niacinamide 2%/Spironolactone 2%/Clindamycin 1% Topical Gel

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Mupirocin 2% Facial Wash

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 7%/Niacinamide 2%/Biotin 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Niacinamide 5%/Clindamycin 1% Topical Cream

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Tea Tree Oil 2.5% Topical Cream

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Urea 10% Face Wash

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Clindamycin 1% 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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