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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

CheckboxMisoprostol 0.0024%/Diphenhydramine HCl 0.1%/Lidocaine HCl 1% Oral Rinse

Add

Adding

Radio 3

CheckboxMontelukast 1 mg/ml/Ketotifen 0.5 mg/ml/Budesonide 0.5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxMometasone Furoate 0.1% Topical Gel

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Adding

Radio 3

CheckboxMisoprostol 0.0024%/Ciprofloxacin HCl 2% Topical Gel

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Adding

Radio 3

CheckboxMontelukast 1%/Naltrexone HCl 0.5%/Ketotifen 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024%/Metronidazole 2% Topical Cream

Add

Adding

Radio 3

CheckboxMometasone Furoate 0.1%/Ketotifen 0.05% Topical Shampoo

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Adding

Radio 3

CheckboxMisoprostol 0.0024% Topical Gel

Add

Adding

Radio 3

CheckboxMontelukast 1%/Ketotifen 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxMometasone Furoate 0.6 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxMisoprostol 0.0024%/Phenytoin 5%/Metronidazole 2% Topical Gel

Add

Adding

Radio 3

CheckboxMisoprostol 0.0024% Oral Rinse

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Adding

Radio 3

CheckboxMontelukast 3 mg/Loratadine 2 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxMisoprostol 400 Mcg/Gm Vaginal Gel

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Adding

Radio 3

CheckboxMinoxidil 10% Topical Solution

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Adding

Radio 3

CheckboxMinoxidil 10%/Biotin 0.2% Topical Solution

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Adding

Radio 3

CheckboxMinoxidil 15% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 7%/Azelaic Acid 5%/Hydrocortisone 1%/Pyridoxine HCl 1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Progesterone 0.5%/Vitamin E Acetate 10 U/ml Topical Lotion

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Adding

Radio 3

CheckboxMinoxidil 8.5%/Finasteride 0.1% Scalp Solution

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Adding

Radio 3

CheckboxMinoxidil 10%/Zinc Pyrithione 1% Topical Suspension

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Adding

Radio 3

CheckboxMinoxidil 7.5%/Naltrexone HCl 0.5% Topical Gel

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Adding

Radio 3

CheckboxMinoxidil 10%/Finasteride 0.1% Topical Solution

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Adding

Radio 3

CheckboxMinoxidil 10% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 15%/Azelaic Acid 2%/Ketoconazole 2%/Biotin 0.25%/Finasteride 0.25%/Tea Tree Oil 0.25%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10% Topical Shampoo

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Progesterone 0.25%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 12.5%/Azelaic Acid 5%/Tretinoin 0.025% Topical Cream

Add

Adding

Radio 3

CheckboxMinoxidil 8.5%/Finasteride 0.1% Topical Shampoo

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Finasteride 0.1% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Azelaic Acid 5% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Finasteride 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Biotin 0.2%/Finasteride 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 10%/Finasteride 0.1%/Tretinoin 0.025%/Fluocinolone Acetonide 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 12.5% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 6%/Estriol 0.1%/Zinc Acetate 0.1% Topical Solution

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Adding

Radio 3

CheckboxMinoxidil 5%/Melatonin 0.1%/Finasteride 0.1%/Tretinoin 0.05% Scalp Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Clobetasol Propionate 0.05% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Estradiol 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.01% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.25%/Coenzyme Q-10 0.1%/Melatonin 0.1%/Cyanocobalamin 0.07% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.5%/Vitamin E Acetate 10 IU/ml Scalp Solution

Add

Adding

Radio 3

CheckboxMinoxidil 7.5%/Estradiol 0.025%/Finasteride 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tea Tree Oil 1%/Niacinamide 0.5%/Finasteride 0.016%/Tretinoin 0.01% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Dutasteride 0.05%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.25%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tacrolimus 0.3%/Clobetasol Propionate 0.05% Topical Foam

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Finasteride 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.01%/Betamethasone Valerate 0.05%/Melatonin 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Finasteride 0.25%/Vitamin E Acetate 0.1%/Fluocinolone Acetonide 0.01%/Tretinoin 0.01% Scalp Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Azelaic Acid 1.5%/Dutasteride 0.05% Topical Foam

Add

Adding

Radio 3

CheckboxMinoxidil 6%/Finasteride 0.1%/Tretinoin 0.0125%/Triamcinolone 0.0125%/Dutasteride 0.005% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.025%/Finasteride 0.05% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tacrolimus 0.1% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Finasteride 0.1%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Finasteride 0.1%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Progesterone 0.25%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Dutasteride 0.05%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Ketoconazole 2%/Finasteride 0.5% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.01%/Fluocinolone Acetonide 0.01%/Vitamin E Acetate Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 5%/Tretinoin 0.025% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 0.5%/Tretinoin 0.025% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 2.5 mg/ml Oral/Sublingual Solution

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Adding

Radio 3

CheckboxMinoxidil 1% Topical Solution

Add

Adding

Radio 3

CheckboxMinocycline 50 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMinoxidil 5% Topical Lotion

Add

Adding

Radio 3

CheckboxMinoxidil 3% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 0.5%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxMinocycline 100 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMinoxidil 1 mg Capsules

Add

Adding

Radio 3

CheckboxMinocycline 4% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 3%/Finasteride 0.25% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 2%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 1%/Tretinoin 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 3% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 2% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 4% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 2%/Tretinoin 0.025%/Finasteride 0.05%/Progesterone 0.05% Topical Solution

Add

Adding

Radio 3

CheckboxMidazolam 25 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxMinoxidil 5% Shampoo

Add

Adding

Radio 3

CheckboxMinoxidil 2% Topical Solution

Add

Adding

Radio 3

CheckboxMinoxidil 2.5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMinoxidil 2%/Progesterone 0.5%/Estradiol 0.02% Topical Foam

Add

Adding

Radio 3

CheckboxMinoxidil 5% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 3%/Finasteride 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxMinoxidil 0.25 mg Capsules

Add

Adding

Radio 3

CheckboxMinocycline 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxMinoxidil 1% Topical Gel

Add

Adding

Radio 3

CheckboxMiconazole Nitrate 100 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxMiconazole Nitrate 1% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxMiconazole Nitrate 2%/DMSO Topical Solution

Add

Adding

Radio 3

CheckboxMexiletine HCl 150 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMiconazole Nitrate 10 mg Troche

Add

Adding

Radio 3

CheckboxMidazolam 2 mg/ml Oral Solution (Gluten Free)

Add

Adding

Radio 3

CheckboxMexiletine HCl 200 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxMidazolam 2 mg/ml Oral Suspension (Gluten Free)

Add

Adding

Radio 3

CheckboxMidazolam 5 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxMiconazole 2%/Salicylic Acid 2%/Fluocinolone Acetonide 0.025% Topical Shampoo

Add

Adding

Radio 3

CheckboxMiconazole Nitrate 6% 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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