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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

CheckboxBenzoic Acid 12%/Salicylic Acid 6% Topical Ointment

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Erythromycin 3%/Biotin 0.1% Topical Cream

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Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Erythromycin 3% Topical Cream

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Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Erythromycin 3% Topical Gel

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Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Glycolic Acid 3% Topical Gel

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Topical Cream

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Adding

Radio 3

CheckboxBenzocaine 10%/Lidocaine 5%/Tetracaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Topical Anhydrous Cream

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Adding

Radio 3

CheckboxBenzocaine 20% Otic Solution

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Adding

Radio 3

CheckboxBenzocaine 20%/Iodoform 15.8%/Eugenol 13.7% Dental Paste

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Adding

Radio 3

CheckboxBenzocaine 10%/Lidocaine 5%/Tetracaine 2% Topical Cream

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Adding

Radio 3

CheckboxBenzocaine 165 mg/Zinc Oxide 170 mg/Benzalkonium Chloride 25 mg Suppository

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4%/Phenylephrine HCl 0.01% Topical Gel

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Adding

Radio 3

CheckboxBenzocaine 30%/Caffeine 0.4% Oral Gel

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Adding

Radio 3

CheckboxBenzocaine 15% Topical Gel

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Adding

Radio 3

CheckboxBenzocaine 20% Oral Adhesive Paste

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4%/DMSO Topical Cream

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Adding

Radio 3

CheckboxBenzocaine 25% Compound Dental Liquid

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Adding

Radio 3

CheckboxBenzocaine 25%/Capsicum Oleoresin 1%/Clove Dental Poultice

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Topical Gel

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Adding

Radio 3

CheckboxBenzoic Acid 2.5%/Aluminum Chlorohydrate 10%/Salicylic Acid 2.5%/Boric Acid 10% Foot Powder

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Adding

Radio 3

CheckboxBenzoic Acid 6%/Salicylic Acid 2.5%/Sulfur 4.6% Topical Ointment

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Adding

Radio 3

CheckboxBenzocaine 16.7% Dry Socket Paste

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Topical Ointment

Add

Adding

Radio 3

CheckboxBenzocaine 20% Topical Ointment

Add

Adding

Radio 3

CheckboxBenzocaine 0.47% Compound Oral Concentrate

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Adding

Radio 3

CheckboxBenzocaine 10% Topical Dental Solution

Add

Adding

Radio 3

CheckboxBenzocaine 10% Otic Solution

Add

Adding

Radio 3

CheckboxBenzocaine 2%/Camphor 0.5%/Menthol 0.5% Topical Gel (Zosil®) (Vet-Equine)

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Adding

Radio 3

CheckboxBenzocaine 3%/Menthol 1%/Methyl Salicylate 25% Topical Emulsion

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Adding

Radio 3

CheckboxBenzocaine 2.3% Throat Spray

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Adding

Radio 3

CheckboxBenzalkonium Chloride 17% Topical Solution

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Adding

Radio 3

CheckboxBenazepril HCl 5 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxBenzalkonium Chloride 0.5% Topical Nail Gel

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Adding

Radio 3

CheckboxBenzocaine 2%/Menthol 0.2%/Thymol 0.2% Troche

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Adding

Radio 3

CheckboxBenzalkonium Chloride 0.15% Antiseptic Gel

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Adding

Radio 3

CheckboxBenzocaine 0.5%/Menthol/Phenol Compound Topical Lotion

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Adding

Radio 3

CheckboxBenzocaine 2%/Camphor 0.5%/Menthol 0.5% Compound Topical Gel (Vet-Equine)

Add

Adding

Radio 3

CheckboxBenzocaine 0.5%/Hydrocortisone 0.25% Rectal Ointment

Add

Adding

Radio 3

CheckboxBenzocaine 5%/Triamcinolone Acetonide 0.1%/Benzalkonium Chloride Topical Solution

Add

Adding

Radio 3

CheckboxBenzocaine 2%/Aluminum Chloride Hexahydrate 20%/Urea 10% Topical Solution

Add

Adding

Radio 3

CheckboxBenzocaine 6%/Chlorobutanol 5% Dental Gauze Solution

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Adding

Radio 3

CheckboxBenzalkonium Chloride 0.1% Gel

Add

Adding

Radio 3

CheckboxBenzocaine 2%/Hydroxyquinoline Sulfate 5% Rectal Ointment

Add

Adding

Radio 3

CheckboxBenazepril HCl 5 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxBenzocaine 6.3%/Menthol 0.5% Topical Cream

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Adding

Radio 3

CheckboxBenzalkonium Chloride 0.15% Antiseptic Solution

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Adding

Radio 3

CheckboxBaclofen 2% Topical Gel

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Adding

Radio 3

CheckboxBaclofen 2%/Diazepam 1%/Ketamine HCl 0.5% Poloxamer Vaginal Gel

Add

Adding

Radio 3

CheckboxBacitracin 5,000 U/ml Mouthwash

Add

Adding

Radio 3

CheckboxBaclofen 2%/Ketoprofen 10%/Lidocaine 5%/Gabapentin 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Diazepam 1%/Ketamine HCl 0.5% Vaginal Gel

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Adding

Radio 3

CheckboxBelladonna Extract 16.2 mg/Morphine Sulfate 7.5 mg Suppository

Add

Adding

Radio 3

CheckboxBelladonna Extract 15 mg Compound Suppository

Add

Adding

Radio 3

CheckboxBaclofen 2%/Guaifenesin 5%/Cyclobenzaprine HCl 2% Rectal Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Naltrexone HCl 1% Topical/Vaginal

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Adding

Radio 3

CheckboxBelladonna Extract 20 mg/Phenobarbital 50 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxBaclofen 2%/Gabapentin 6%/Amitriptyline HCl 2%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 2%/Gabapentin 2%/Diazepam 1 mg Suppository

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Adding

Radio 3

CheckboxBaclofen 20 mg/Guaifenesin 50 mg/Cyclobenzaprine HCl 20 mg Suppository

Add

Adding

Radio 3

CheckboxBaclofen 5 mg Troche

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Adding

Radio 3

CheckboxBelladonna Alkaloids/Phenobarbital 48.6 mg Slow Release Capsules

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Adding

Radio 3

CheckboxBelladonna Extract 16.2 mg/Morphine Sulfate 3.75 mg Suppository

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Adding

Radio 3

CheckboxBaclofen 2%/Ketoprofen 10%/Lidocaine 5%/Gabapentin 5% Topical Cream

Add

Adding

Radio 3

CheckboxBaclofen 20 mg/Amitriptyline HCl 20 mg Suppository

Add

Adding

Radio 3

CheckboxBaclofen 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxBenazepril HCl 2 mg/0.1 ml Topical Gel (Vet)

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Adding

Radio 3

CheckboxBelladonna Extract 15 mg/Hydrocortisone 20 mg Suppository

Add

Adding

Radio 3

CheckboxBacitracin 500 U/Gm Topical Ointment

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Adding

Radio 3

CheckboxBaclofen 20 mg/Gm/Diazepam 10 mg/Gm Vaginal Gel

Add

Adding

Radio 3

CheckboxBeclomethasone Dipropionate 0.025%/Ipratropium Bromide 0.012% Nasal Suspension

Add

Adding

Radio 3

CheckboxBaclofen 2%/Ketoprofen 10%/Lidocaine 5%/Gabapentin 5% Topical Cream

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Kojic Acid 4%/Phytic Acid 2% Topical Cream

Add

Adding

Radio 3

CheckboxAzithromycin 50 mg Capsules

Add

Adding

Radio 3

CheckboxAzelastine HCl 0.15%/Brimonidine Tartrate 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxAzithromycin 50 mg/Itraconazole 50 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxAzelastine HCl 500 Mcg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Kojic Acid 4% Topical Solution

Add

Adding

Radio 3

CheckboxAzelaic Acid 15% Topical Cream

Add

Adding

Radio 3

CheckboxAzithromycin 100 mg/5 ml Oral Suspension (Gluten Free)

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Adding

Radio 3

CheckboxAzelaic Acid 18%/Niacinamide 4%/Brimonidine Tartrate 0.4% Topical Cream

Add

Adding

Radio 3

CheckboxAzelaic Acid 20%/Hydrocortisone 1%/Cetyl Alcohol Topical Lotion

Add

Adding

Radio 3

CheckboxAzelastine Hydrochloride 0.175% Nasal Spray

Add

Adding

Radio 3

CheckboxAzelaic Acid 10%/Kojic Acid 4%/Ascorbic Acid 1% Topical Solution

Add

Adding

Radio 3

CheckboxAzithromycin 50 mg/Fluconazole 15 mg/Fluticasone Propionate 3 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxAzelaic Acid 20%/Kojic Acid 2% Topical Solution

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Sulfacetamide 10%/Metronidazole 2%/Hydrocortisone 1% Topical Gel

Add

Adding

Radio 3

CheckboxAzithromycin 150 mg/ml Oral Suspension (Vet-Avian)

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Ketotifen 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Oxymetazoline HCl 1%/Ketotifen 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxAzelaic Acid 15% Topical Ointment

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Niacinamide 4% Topical Solution

Add

Adding

Radio 3

CheckboxAzelastine Hydrochloride 0.175%/Ketotifen 0.05%/Mometasone Furoate 0.06% Nasal Spray

Add

Adding

Radio 3

CheckboxAzelastine HCl 350 mcg/Budesonide 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

Add

Adding

Radio 3

CheckboxAzithromycin 200 mg/5 ml Oral Suspension (Gluten Free)

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Ketotifen 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxAzelaic Acid 15%/Ivermectin 1%/Metronidazole 1% Topical Gel

Add

Adding

Radio 3

CheckboxAzithromycin 200 mg/ml Anhydrous Oral Paste (Vet-Equine)

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Adding

Radio 3

CheckboxAzelaic Acid 20%/Hydroquinone 8% Topical Cream

Add

Adding

Radio 3

CheckboxAzelastine Hydrochloride 0.175%/Budesonide 0.06% Nasal Spray

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

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Thank you! Your submission has been received!

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