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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

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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

CheckboxAmitriptyline HCl 2%/Clonidine HCl 0.232% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline 5%/Ketamine HCl 5.75%/Ketoprofen 10% Topical Ointment

Add

Adding

Radio 3

Checkbox2-Deoxy-D-Glucose 0.2% Oral Rinse

Add

Adding

Radio 3

CheckboxAtropine 0.05% Ophthalmic Drops

Add

Adding

Radio 3

CheckboxAtropine 0.02% Ophthalmic Drops

Add

Adding

Radio 3

CheckboxAtropine 0.01% Ophthalmic Drops

Add

Adding

Radio 3

CheckboxLidocaine 3%/Hydrocortisone 2% Rectal Rocket Suppository

Add

Adding

Radio 3

CheckboxMupirocin 1%/Betamethasone 0.05%/Miconazole 2% Topical Ointment

Add

Adding

Radio 3

CheckboxVardenafil HCl 20 mg Oral Dissolve Tablets

Add

Adding

Radio 3

CheckboxVardenafil HCl 20 mg Troche

Add

Adding

Radio 3

CheckboxVardenafil HCl 10 mg Troche

Add

Adding

Radio 3

CheckboxVardenafil HCl 5 mg Troche

Add

Adding

Radio 3

CheckboxTadalafil 20 mg Rapid Dissolve Tablets

Add

Adding

Radio 3

CheckboxTadalafil 10 mg Rapid Dissolve Tablets

Add

Adding

Radio 3

CheckboxTadalafil 5 mg Rapid Dissolve Tablets

Add

Adding

Radio 3

CheckboxTadalafil 20 mg Troche

Add

Adding

Radio 3

CheckboxTadalafil 10 mg Troche

Add

Adding

Radio 3

CheckboxTadalafil 5 mg Troche

Add

Adding

Radio 3

CheckboxTadalafil 20 mg Tablets

Add

Adding

Radio 3

CheckboxTadalafil 10 mg Tablets

Add

Adding

Radio 3

CheckboxTadalafil 5 mg Tablets

Add

Adding

Radio 3

CheckboxSildenafil 100 mg Oral Dissolve Tablets

Add

Adding

Radio 3

CheckboxSildenafil 50 mg Oral Dissolve Tablets

Add

Adding

Radio 3

CheckboxSildenafil 100 mg Troche

Add

Adding

Radio 3

CheckboxSildenafil 50 mg Troche

Add

Adding

Radio 3

CheckboxSildenafil 25 mg Troche

Add

Adding

Radio 3

CheckboxSildenafil 100 mg Tablets

Add

Adding

Radio 3

CheckboxSildenafil 50 mg Tablets

Add

Adding

Radio 3

CheckboxSildenafil 25 mg Tablets

Add

Adding

Radio 3

CheckboxSildenafil 20 mg Tablets

Add

Adding

Radio 3

CheckboxAlprostadil 40 mcg/Atropine 0.15 mg/Papaverine 30 mg/Phentolamine 2 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 30 mcg/Atropine 0.15 mg/Papaverine 30 mg/Phentolamine 2 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 20 mcg/Atropine 0.15 mg/Papaverine 30 mg/Phentolamine 2 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 40 mcg/Papaverine 30 mg/Phentolamine 2 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 40 mcg/Papaverine 30 mg/Phentolamine 1 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 30 mcg/Papaverine 30 mg/Phentolamine 2 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 30 mcg/Papaverine 30 mg/Phentolamine 1 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 20 mcg/Papaverine 30 mg/Phentolamine 2 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 20 mcg/Papaverine 30 mg/Phentolamine 1 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 10 mcg/Papaverine 30 mg/Phentolamine 1 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 5 mcg/Papaverine 30 mg/Phentolamine 1 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 40 mcg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 20 mcg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAtropine 0.15 mg/Papaverine 20 mg/Phentolamine 2 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxPapaverine 30 mg/Phentolamine 2 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxPapaverine 30 mg/Phentolamine 1 mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 1000 mcg/Papaverine 7.5 mg/Phentolamine 1 mg/ml Urethral Gel

Add

Adding

Radio 3

CheckboxAlprostadil 750 mcg/Papaverine 7.5 mg/Phentolamine 1 mg/ml Urethral Gel

Add

Adding

Radio 3

CheckboxAlprostadil 500 mcg/Papaverine 7.5 mg/Phentolamine 1 mg/ml Urethral Gel

Add

Adding

Radio 3

CheckboxAlprostadil 250 mcg/Papaverine 7.5 mg/Phentolamine 1 mg/ml Urethral Gel

Add

Adding

Radio 3

CheckboxPapaverine 7.5 mg/Phentolamine 2 mg/ml Urethral Gel

Add

Adding

Radio 3

CheckboxPapaverine 7.5 mg/Phentolamine 1 mg/ml Urethral Gel

Add

Adding

Radio 3

CheckboxNaltrexone HCl 9 mg Capsules

Add

Adding

Radio 3

CheckboxNaltrexone HCl 6 mg Capsules

Add

Adding

Radio 3

CheckboxNaltrexone HCl 5 mg Capsules

Add

Adding

Radio 3

CheckboxNaltrexone HCl 4.5 mg Capsules

Add

Adding

Radio 3

CheckboxNaltrexone HCl 3 mg Capsules

Add

Adding

Radio 3

CheckboxNaltrexone HCl 1.5 mg Capsules

Add

Adding

Radio 3

CheckboxNaltrexone HCl 1 mg Capsules

Add

Adding

Radio 3

CheckboxNaltrexone HCl 0.5 mg Capsules

Add

Adding

Radio 3

CheckboxNaltrexone HCl 3 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxNaltrexone HCl 4.5 mg Tablets

Add

Adding

Radio 3

CheckboxNaltrexone HCl 3 mg Tablets

Add

Adding

Radio 3

CheckboxNaltrexone HCl 1.5 mg Tablets

Add

Adding

Radio 3

CheckboxSirolimus (Rapamycin) 0.001% Topical Cream

Add

Adding

Radio 3

CheckboxTadalafil 15 mg Capsules

Add

Adding

Radio 3

CheckboxTadalafil 7.5 mg Capsules

Add

Adding

Radio 3

CheckboxPhenylbutazone 10% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxZonisamide 400 mg Capsules

Add

Adding

Radio 3

CheckboxZonisamide 12.5 mg Capsules

Add

Adding

Radio 3

CheckboxZonisamide 25 mg Suppository

Add

Adding

Radio 3

CheckboxZinc Sulfate Replacement Solution (3 mg/mL of Elemental Zinc)

Add

Adding

Radio 3

CheckboxZinc Sulfate 20% Topical Gel

Add

Adding

Radio 3

CheckboxZonisamide 10 mg/ml To 100 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxZinc Sulfate Monohydrate 0.1% Oral Solution

Add

Adding

Radio 3

CheckboxZonisamide 100 mg Suppository

Add

Adding

Radio 3

CheckboxZonisamide 25 mg/0.1 ml Topical Lipoderm® (Vet)

Add

Adding

Radio 3

CheckboxZinc Sulfate Monohydrate 137 mg Capsules

Add

Adding

Radio 3

CheckboxZinc Sulfate 10%/Manganese Chloride 0.5% Oral Solution

Add

Adding

Radio 3

CheckboxZonisamide 75 mg Capsules

Add

Adding

Radio 3

CheckboxZonisamide 150 mg Capsules

Add

Adding

Radio 3

CheckboxZinc Pyrithione 1%/Clobetasol Propionate 0.05% Shampoo

Add

Adding

Radio 3

CheckboxZinc Sulfate 3.23 mg/Gm Vaginal Gel

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Hydrocortisone 1%/Ibuprofen 2% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Pyrithione 2% Topical Spray

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Cyanocobalamin 0.07% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Cyanocobalamin 0.07%/Clobetasol Propionate 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Tacrolimus 0.1%/Cyanocobalamin 0.07%/ Topical Cream

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Clobetasol Propionate 0.05% Topical Spray

Add

Adding

Radio 3

CheckboxZinc Sulfate 0.025% Mouth Rinse

Add

Adding

Radio 3

CheckboxZinc Pyrithione 1%/Ketoconazole 1% Shampoo

Add

Adding

Radio 3

CheckboxZinc Pyrithione 2% Topical Gel

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Clobetasol Propionate 0.05%/Cyanocobalamin 0.07% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Sulfate 1%/Aluminum Sulfate 5% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Cyanocobalamin 0.07%/Clobetasol Propionate 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxZinc Pyrithione 0.2%/Cyanocobalamin 0.07% Topical Gel

Add

Adding

Radio 3

CheckboxZinc Gluconate 100 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxZinc Oxide 5%/Aloe Vera Oil 2%/Vitamin A Palmitate 5000 IU/ml/Vitamin E Acetate 0.1% Topical Liquid

Add

Adding

Radio 3

CheckboxZinc Oxide 10%/Hydroxyquinoline Sulfate Topical Ointment

Add

Adding

Radio 3

CheckboxZinc Oxide 3% 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.

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