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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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Visit the Tutorials tab to learn more.

First

Last

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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

CheckboxArbutin 5% Topical Cream

Add

Adding

Radio 3

CheckboxAmphotericin B 5 mg/mL Nasal Solution

Add

Adding

Radio 3

CheckboxAllantoin 1% Topical Gel

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 15% in Cyclomethicone 10% Topical Lotion

Add

Adding

Radio 3

CheckboxAprepitant 20 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAscorbic Acid 1.5%/Glycolic Acid 5%/Hydrocortisone 1%/Hydroquinone 5% Topical Lotion

Add

Adding

Radio 3

CheckboxAmikacin Sulfate 5% Topical Paste

Add

Adding

Radio 3

CheckboxAtenolol 1 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAscorbic Acid 10 mg/mL/L-Arginine 250 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxAmlodipine Besylate 2.5 mg/1 mL Topical Cream

Add

Adding

Radio 3

CheckboxAluminum Sulfate 5 mg/g/Ferrous Sulfate 3 mg/g/Zinc Sulfate 3 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxAscorbic Acid 15% Topical Cream

Add

Adding

Radio 3

CheckboxApomorphine HCl 15 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg/g/Gabapentin 60 mg/g/Ketamine HCl 50 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxAzathioprine Sodium 10 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxApomorphine HCl 3 mg/mL Sublingual Solution

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 40 mg/mL/Dextromethorphan HBr 200 mg/mL/Tramadol HCl 50 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg/mL/Baclofen 50 mg/mL/Ketamine HCl 50 mg/mL/Ketoprofen 100 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 20 mg/mL/Ketamine HCl 50 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 40%/Salicylic Acid 4% Topical Gel

Add

Adding

Radio 3

CheckboxAzelaic Acid 20% Topical Gel

Add

Adding

Radio 3

CheckboxAtropine Sulfate 0.1 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAtorvastatin 10 mg Slow Release (ME4M) Oral Capsules

Add

Adding

Radio 3

CheckboxAmiloride HCl 1 mg/mL Oral Solution

Add

Adding

Radio 3

CheckboxAlbendazole 40 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAscorbic Acid 12.5 mg/mL/L-arginine 100 mg/mL Topical Gel

Add

Adding

Radio 3

CheckboxAlbendazole 20 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAspirin 380 mg/Caffeine 30 mg/Codeine Phosphate 30 mg Capsules

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 0.05%/Atropine Sulfate 0.01%/Lidocaine HCl 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxAtenolol 100 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAluminum Sulfate 5 mg/g/Benzocaine 20 mg/mL/Menthol 3 mg/mL/Zinc Sulfate 3 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxAmpicillin Sodium 50 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Carbamazepine 2%/Gabapentin 10%/Ketoprofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxAtropine Sulfate 2 mg/mL Sublingual Solution

Add

Adding

Radio 3

CheckboxAcetylcysteine Sodium 86.5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAcyclovir 200 mg Vaginal Suppositories

Add

Adding

Radio 3

CheckboxAcyclovir 5%/2-Deoxy-D-glucose 2%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxAcyclovir 50 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAcetylcysteine 150 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxAcyclovir 10 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxAcetaminophen 65 mg/mL/Tramadol HCl 7.5 mg/mL Oral Suspension

Add

Adding

Radio 3

CheckboxAcetylcysteine 1200 mg Capsules

Add

Adding

Radio 3

CheckboxAcetaminophen 500 mg/g/Pentoxifylline 50 mg/g Topical Gel

Add

Adding

Radio 3

CheckboxEstradiol 0.02% Vaginal Cream

Add

Adding

Radio 3

CheckboxMidazolam 5 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxKetamine 10 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxHydromorphone 1 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxHydromorphone 5 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxHydromorphone 40 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxHydromorphone 20 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxKetamine 50 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxDexmedetomidine HCl 40 mcg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxMorphine Sulfate 5 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxMorphine Sulfate 40 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxHydromorphone 10 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxHaloperidol Lactate 1 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxMorphine Sulfate 20 mg/mL Intravenous Infusion

Add

Adding

Radio 3

CheckboxPolymyxin B 1 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxVoriconazole 2% Ophthalmic Solution

Add

Adding

Radio 3

CheckboxCeftriaxone 50 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxOxacillin 66 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxMethylprednisolone Sodium Succinate 1% Ophthalmic Solution

Add

Adding

Radio 3

CheckboxFluconazole 2 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxPolymyxin B 5 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxAmphotericin PF 5 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxAmikacin 50 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxHydrocortisone 25 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxPenicillin G Potassium 100,000mU/ml Ophthalmic Solution

Add

Adding

Radio 3

CheckboxCefazolin 50 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxPenicillin G Potassium 333,000mU/ml Ophthalmic Solution

Add

Adding

Radio 3

CheckboxColistimethate 50 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxAmphotericin PF 2 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxAmikacin 25 mg/mL Ophthalmic Solution

Add

Adding

Radio 3

CheckboxTestosterone 0.1% to 20% Vaginal Gel

Add

Adding

Radio 3

CheckboxClomiphene Citrate 5%/Testosterone 5% Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxTestosterone 2% Topical Gel

Add

Adding

Radio 3

CheckboxClomiphene Citrate 2%/Testosterone 2% Topical Gel

Add

Adding

Radio 3

CheckboxClomiphene Citrate 2%/Testosterone 2% Oral Dissolve Tablet

Add

Adding

Radio 3

CheckboxTestosterone 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxTestosterone 10 mg Oral Dissolve Tablet

Add

Adding

Radio 3

CheckboxTestosterone 5 mg Oral Dissolve Tablet

Add

Adding

Radio 3

CheckboxGabapentin 6%/Estriol 0.1%/Testosterone 0.1% Vaginal Cream

Add

Adding

Radio 3

CheckboxTestosterone 1% Vaginal Suppository

Add

Adding

Radio 3

CheckboxGabapentin 6%/Estriol 0.1%/Testosterone 0.1% Vaginal Suppository

Add

Adding

Radio 3

CheckboxClomiphene Citrate 2%/Testosterone 2% Troche

Add

Adding

Radio 3

CheckboxEstradiol 0.01%/Testosterone 0.1% Vaginal Suppository

Add

Adding

Radio 3

CheckboxSemaglutide 1.5 mg/mL Sublingual Suspension

Add

Adding

Radio 3

CheckboxSemaglutide 1.25 mg/mL Sublingual Suspension

Add

Adding

Radio 3

CheckboxSemaglutide 1 mg/mL Sublingual Suspension

Add

Adding

Radio 3

CheckboxSemaglutide 0.75 mg/mL Sublingual Suspension

Add

Adding

Radio 3

CheckboxSemaglutide 0.5 mg/mL Sublingual Suspension

Add

Adding

Radio 3

CheckboxTrazodone HCl 100 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxTylosin 325 mg Oral Capsules

Add

Adding

Radio 3

CheckboxZiprasidone HCl 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTramadol HCl 10 mg/ml Veterinary Oral Liquid

Add

Adding

Radio 3

CheckboxTrichloroacetic Acid 50% Topical Liquid

Add

Adding

Radio 3

CheckboxTrilostane 10 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTranexamic Acid 250 mg Oral Capsules

Add

Adding

Radio 3

CheckboxVerapamil 1% Topical Ointment

Add

Adding

Radio 3

CheckboxValproic Acid 250 mg Rectal Suppository

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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