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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.

Need help?

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

CheckboxTranexamic Acid 10% Topical Liquid

Add

Adding

Radio 3

CheckboxTrilostane 30 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTylosin 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTrichloroacetic Acid 30% Topical Liquid

Add

Adding

Radio 3

CheckboxUrea 40% Topical Paste

Add

Adding

Radio 3

CheckboxTrilostane 80 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTramadol HCl 50 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxVitamin K1 8% Topical Cream

Add

Adding

Radio 3

CheckboxTriamcinolone 0.1% Mouthwash Liquid

Add

Adding

Radio 3

CheckboxTriamcinolone Acetonide 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxVitamin K1 5% Topical Cream

Add

Adding

Radio 3

CheckboxUrea 10% Topical Ointment

Add

Adding

Radio 3

CheckboxTranexamic Acid 5% Nasal Spray

Add

Adding

Radio 3

CheckboxVitamin E Acetate 500 mg Rectal Suppository

Add

Adding

Radio 3

CheckboxTramadol HCl 25 mg Oral Slow Release (MEM4) Capsules

Add

Adding

Radio 3

CheckboxTriamcinolone Acetonide 0.05%/Zinc Oxide 10% Topical Ointment

Add

Adding

Radio 3

CheckboxTrichloroacetic Acid 30% Topical Ointment

Add

Adding

Radio 3

CheckboxZinc Sulfate Heptahydrate 25 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxTrilostane 15 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxVerapamil HCl 8% Rectal Ointment

Add

Adding

Radio 3

CheckboxVoriconazole 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxVitamin A Palmitate 2500 IU/1.25 g/Vitamin D3 4000 IU/1.25 g Topical Cream

Add

Adding

Radio 3

CheckboxVerapamil HCl 240 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxVitamin K1 9% Topical Cream

Add

Adding

Radio 3

CheckboxTranexamic Acid 3% Topical Liquid

Add

Adding

Radio 3

CheckboxVitamin E Acetate 30 IU Vaginal Suppository

Add

Adding

Radio 3

CheckboxVitamin E 400 Units Vaginal Suppository

Add

Adding

Radio 3

CheckboxTriamcinolone 0.1% Oral Paste

Add

Adding

Radio 3

CheckboxVitamin E Acetate 30 IU/g Topical Cream

Add

Adding

Radio 3

CheckboxXylitol 5% Nasal Spray

Add

Adding

Radio 3

CheckboxZonisamide 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTretinoin 0.02%/Hydroquinone 1%/Triamcinolone Acetonide 0.03% Topical Cream

Add

Adding

Radio 3

CheckboxTriamcinolone 4.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTranexamic Acid 5% Nasal Gel

Add

Adding

Radio 3

CheckboxTrichloroacetic Acid 20% Topical Liquid

Add

Adding

Radio 3

CheckboxVitamin E Acetate 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTrichloroacetic Acid 20% Topical Lotion

Add

Adding

Radio 3

CheckboxTrazodone HCl 135 mg/ml Oral Oil Liquid

Add

Adding

Radio 3

CheckboxVitamin E Acetate 20% Topical Gel

Add

Adding

Radio 3

CheckboxVerapamil HCl 3% Topical Gel

Add

Adding

Radio 3

CheckboxTrimethoprim 5 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTretinoin 0.3% Topical Liquid

Add

Adding

Radio 3

CheckboxVancomycin HCl 0.1025% Topical Cream

Add

Adding

Radio 3

CheckboxVerapamil HCl 8% Transdermal Cream

Add

Adding

Radio 3

CheckboxUrsodiol 62.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxZinc Sulfate Heptahydrate 220 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxUrea 30 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTranexamic Acid 2% Topical Paste

Add

Adding

Radio 3

CheckboxTramadol HCl 45 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTriazolam 0.25 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.25%/Clobetasol Propionate 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxUrsodiol 150 mg Oral Capsules

Add

Adding

Radio 3

CheckboxUrea 40% Topical Gel

Add

Adding

Radio 3

CheckboxTrimethoprim 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTylosin Tartrate 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxZolpidem Tartrate 5 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxUrsodiol 50 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTriamcinolone 0.025% Topical Shampoo

Add

Adding

Radio 3

CheckboxTranexamic Acid 100 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxWitch Hazel 5% Rectal Suppository

Add

Adding

Radio 3

CheckboxUrea 15% Topical Foam

Add

Adding

Radio 3

CheckboxVenlafaxine 18.75 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxVerapamil HCl 15% Transdermal Cream

Add

Adding

Radio 3

CheckboxTrazodone HCl 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxVitamin A Palmitate 2000 IU/g/Vitamin D3 3000 IU/g Topical Cream

Add

Adding

Radio 3

CheckboxVitamin K1 13.8 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxUrsodiol 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTriamcinolone Acetonide 0.2% Oral Rinse

Add

Adding

Radio 3

CheckboxZinc Sulfate 75 mg/ml Topical Cream

Add

Adding

Radio 3

CheckboxTramadol HCl 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxZinc Sulfate 72.6 mg/g Topical Cream

Add

Adding

Radio 3

CheckboxUbiquinone 10 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTriamcinolone 0.1%/Lidocaine 1% Oral Paste

Add

Adding

Radio 3

CheckboxVerapamil HCL 15% Topical Cream

Add

Adding

Radio 3

CheckboxVitamin K1 10% Topical Cream

Add

Adding

Radio 3

CheckboxUrsodiol 75 mg Oral Capsules

Add

Adding

Radio 3

CheckboxWarfarin Sodium 1 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxXylitol 10% Nasal Spray

Add

Adding

Radio 3

CheckboxTrilostane 30 mg Oral Capsules

Add

Adding

Radio 3

CheckboxVitamin A Palmitate 5 000 IU/Vitamin E 400 IU Vaginal Suppository

Add

Adding

Radio 3

CheckboxUrsodiol 25 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTrichloroacetic Acid 20% Topical Cream

Add

Adding

Radio 3

CheckboxVancomycin 25 mg/ml Otic Liquid

Add

Adding

Radio 3

CheckboxVerapamil HCl 15% Transdermal Gel

Add

Adding

Radio 3

CheckboxUrea 8 % Topical Cream

Add

Adding

Radio 3

CheckboxZinc Sulfate 2.5% Topical Cream

Add

Adding

Radio 3

CheckboxTretinoin 10 mg/ml Gastric Tube Liquid

Add

Adding

Radio 3

CheckboxTriamcinolone 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxUrsodiol 100 mg Oral Capsules

Add

Adding

Radio 3

CheckboxUrea 30% Oral Liquid

Add

Adding

Radio 3

CheckboxTheophylline 50 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTestosterone 50 mg/g Transdermal Gel

Add

Adding

Radio 3

CheckboxTopiramate 12.5 mg Oral Capsules

Add

Adding

Radio 3

CheckboxTacrolimus 0.03% Ophthalmic Drops

Add

Adding

Radio 3

CheckboxSulfasalazine 125 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxTheophylline 11 mg/0.1 mL Transdermal Gel

Add

Adding

Radio 3

CheckboxTizanidine 4 mg/5 mL Oral Liquid

Add

Adding

Radio 3

CheckboxTetracycline 5% Mouthwash Liquid

Add

Adding

Radio 3

CheckboxTestosterone 25 mg/ml Transdermal Gel

Add

Adding

Radio 3

CheckboxTetracycline HCl 500 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!

Oops! Something went wrong while submitting the form.