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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

CheckboxBetamethasone Valerate 2.4 mg/mL/Lidocaine HCl 20 mg/mL/Miconazole Nitrate 20 mg/mL Topical Spray

Add

Adding

Radio 3

CheckboxBelladonna Leaf 20 mg/Ergotamine Tartrate 2 mg/Caffeine 100 mg/Pentobarbital Sodium 60 mg Suppositories

Add

Adding

Radio 3

CheckboxBumetanide 2 mg Slow Release (ME4M) Oral Capsules

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Adding

Radio 3

CheckboxBuprenorphine HCl 1.5 mg/mL Nasal Spray

Add

Adding

Radio 3

CheckboxBaclofen 2%/Clonidine HCl 0.2% Gabapentin 10%/Ketamine HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxBaclofen 20 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxBismuth Subcarbonate 6.126% Topical Suspension

Add

Adding

Radio 3

CheckboxBetamethasone 0.05% Ultrasound Gel

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Adding

Radio 3

CheckboxBenzocaine 5% Topical Ointment

Add

Adding

Radio 3

CheckboxBenzocaine 1.5%/Phenol 1%/Quinine HCl 0.5%/Tannic Acid 3%/Urea 0.5% Rectal Cream

Add

Adding

Radio 3

CheckboxBetamethasone 0.1%/Neomycin 0.6% Topical Gel Cream

Add

Adding

Radio 3

CheckboxBenzocaine 10 mg/mL/Dexamethasone 1 mg/mL Topical Spray

Add

Adding

Radio 3

CheckboxBismuth Subgallate 300 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxBuprenorphine HCl 6 mg Troches

Add

Adding

Radio 3

CheckboxBeclomethasone Dipropionate Monohydrate 0.42 mg/mL Nasal Solution

Add

Adding

Radio 3

CheckboxBaclofen 1%/Gabapentin 6%/Ketamine 10% Topical Gel

Add

Adding

Radio 3

CheckboxBenzocaine 2%/Vitamin E Acetate 5% Oral Suspension

Add

Adding

Radio 3

CheckboxBuspirone HCl 2.5 mg/0.1 mL Topical Gel

Add

Adding

Radio 3

CheckboxBenzocaine 1%/Bismuth Subgallate 5%/Phenol 1.5%/Zinc Oxide 5% Rectal Ointment

Add

Adding

Radio 3

CheckboxBenzoic Acid 6%/Camphor 0.25%/Salicylic Acid 3% Topical Solution

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxBupivacaine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxBenztropine Mesylate 1.5 mg/mL Oral Suspension

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Adding

Radio 3

CheckboxBudesonide 2 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.025%/Clotrimazole 0.25%/Mupirocin 0.5%/Nystatin 25000 Units/g Topical Ointment

Add

Adding

Radio 3

CheckboxBetahistine Dihydrochloride 5 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxBaclofen 50 mg/mL/Gabapentin 50mg/mL/Ketoprofen 100 mg/mL/Lidocaine 50 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 1 mg/g/Neomycin Sulfate 6 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxBenzocaine 2%/Vitamins A/D Topical Ointment

Add

Adding

Radio 3

CheckboxBenztropine Mesylate 1 mg/Haloperidol 1 mg/Lorazepam 1 mg/Metoclopramide HCl 40 mg Suppositories

Add

Adding

Radio 3

CheckboxBudesonide 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxBupivacaine HCl 1%/Diclofenac Sodium 3%/Gabapentin 3%/Ketamine HCl 10%/Orphenadrine Citrate 5%/Pentoxifylline 3% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 2.4 mg/g/Lidocaine HCl 20 mg/g/Miconazole Nitrate 20 mg/g Topical Spray

Add

Adding

Radio 3

CheckboxBudesonide 0.025% Topical Ointment

Add

Adding

Radio 3

CheckboxBumetanide 1 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxBenzocaine 200 mg/g/Potassium Nitrate 350 mg/g/Tetracaine HCl 100 mg/g Dental Gel

Add

Adding

Radio 3

CheckboxBelladonna Extract 15 mg/Morphine Sulfate 7.5 mg Suppositories

Add

Adding

Radio 3

CheckboxBuprenorphine 0.2 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxBenzocaine 62.5 mg Troches

Add

Adding

Radio 3

CheckboxBumetanide 0.5 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxBoric Acid 2.75%/Xylitol 5% Otic Solution

Add

Adding

Radio 3

CheckboxBetamethasone Valerate 0.025%/Clotrimazole 2.5%/Mupirocin 0.5%/Nystatin 25000 Units/g Topical Ointment

Add

Adding

Radio 3

CheckboxBenzyl Benzoate 10% Topical Lotion

Add

Adding

Radio 3

CheckboxBetamethasone 0.12 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxBenztropine Mesylate 2 mg/5g Topical Gel

Add

Adding

Radio 3

CheckboxBuprenorphine HCl 2 mg/Naloxone HCl Dihydrate 0.5 mg Troches

Add

Adding

Radio 3

CheckboxBoric Acid 0.5%/Kaolin 50%/Methyl Salicylate 3%/Salicylic Acid 0.75% Topical Paste

Add

Adding

Radio 3

CheckboxBuprenorphine 0.1 mg Troches

Add

Adding

Radio 3

CheckboxBetamethasone 0.1%/Doxepin 2% Topical Cream

Add

Adding

Radio 3

CheckboxBelladonna Extract 15 mg/Ergotamine Tartrate 0.5 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.1%/Salicylic Acid 2% Topical Lotion

Add

Adding

Radio 3

CheckboxBenzocaine 5%/Chlorobutanol 5% Topical Ointment

Add

Adding

Radio 3

CheckboxBaclofen 2%/Cyclobenzaprine HCl 2%/Ketoprofen 10%/Lidocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxBupivacaine HCl 10 mg/mL/Diclofenac Sodium 80 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxBenzocaine 2%/Coal Tar Solution 48.5%/Salicylic Acid 1% Topical Solution

Add

Adding

Radio 3

CheckboxAmitriptyline 2%/Carbamazepine 2%/Clonidine 0.1%/Ketamine 2.5% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 1 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxApomorphine 30 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAlbuterol Sulfate 2 mg Suppositories

Add

Adding

Radio 3

CheckboxAcyclovir 50 mg/g/Benzocaine 11 mg/g Lip Balm

Add

Adding

Radio 3

CheckboxAtorvastatin 20 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxAmpicillin Sodium 250 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAllopurinol 1.2 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg/g/Baclofen 20 mg/g/Clonidine HCl 1 mg/g/Gabapentin 60 mg/g/Ketamine HCl 100 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxAmphotericin B 0.4% Topical Gel

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Hydrocortisone Acetate 1% Topical Gel

Add

Adding

Radio 3

CheckboxAscorbic Acid 10%/Dexpanthenol 0.5%/Hyaluronic Acid 1% Topical Cream

Add

Adding

Radio 3

CheckboxAscorbic Acid 2%/Castor Oil 5% Topical Cream

Add

Adding

Radio 3

CheckboxAlpha Lipoic Acid 1%/Niacinamide 3% Topical Gel

Add

Adding

Radio 3

CheckboxAmikacin Sulfate 6.7 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxAllantoin 2% Shampoo

Add

Adding

Radio 3

CheckboxAluminum 20%/Zinc Oxide 40% Topical Paste

Add

Adding

Radio 3

CheckboxAlpha Lipoic Acid 0.5%/Vitamin A Palmitate 0.12%/Vitamin E Acetate 0.4% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Clonidine HCl 0.22%/Gabapentin 6% Topical Gel

Add

Adding

Radio 3

CheckboxAspirin 325 mg/Methocarbamol 400 mg Capsules

Add

Adding

Radio 3

CheckboxApomorphine HCl 10 mg/mL Nasal Solution

Add

Adding

Radio 3

CheckboxAlprazolam 1 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg/mL/Baclofen 20 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxAllantoin 0.1%/Benzocaine 0.5%/Menthol 0.3% Topical Lotion

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Dexamethasone 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 2%/Gabapentin 4%/Ketoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAllopurinol 20 mg/mL Oral Syrup

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5 mg/mL/Buspirone HCl 2.5 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Sodium Lauryl Sulfate 5% Topical Gel

Add

Adding

Radio 3

CheckboxAspirin 85 mg Suppositories

Add

Adding

Radio 3

CheckboxAlbendazole 400 mg Suppositories

Add

Adding

Radio 3

CheckboxAmpicillin Sodium 100 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxAtenolol 50 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg/g/Carbamazepine 20 mg/g/Ketoprofen 20 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxAcyclovir 50 mg/mL/Lidocaine HCl 20 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxAtenolol 25 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxAtropine Sulfate 5 mg/mL Nasal Solution

Add

Adding

Radio 3

CheckboxAscorbic Acid 10 mg/g/L-Arginine 250 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxAllantoin 2.5%/Coal Tar 2% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg/g/Gabapentin 60 mg/g/Ketoprofen 100 mg/g/Lidocaine 100 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxAcyclovir 50 mg/g/Lidocaine 10 mg/g/Sodium Lauryl Sulfate 50 mg/g Topical Stick

Add

Adding

Radio 3

CheckboxAmoxicillin Trihydrate 125 mg Suppositories

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10%/Baclofen 2.5%/Ketamine HCl 5% Topical Gel

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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