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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

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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

CheckboxKetoprofen 10%/Gabapentin 5%/Lidocaine 5%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 5%/Lidocaine HCl 5%/Bupivacaine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Cyclobenzaprine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Lidocaine 5%/Baclofen 2%/Cyclobenzaprine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Gabapentin 5% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Amitriptyline HCl 2%/Carbamazepine 2% Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Piroxicam 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 20 mg/ml Mouth Rinse

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Bupivacaine HCl 1%/Tizanidine HCl 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 5%/Lidocaine HCl 5%/Bupivacaine HCl 1%/Cyclobenzaprine HCl 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 20% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10% Iontophoresis Solution

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Ketamine HCl 5%/Amitriptyline HCl 2%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Lidocaine HCl 5%/Bupivacaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 10%/Gabapentin 5%/Guaifenesin 5% Iontophoresis Solution

Add

Adding

Radio 3

CheckboxKetoconazole 25 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxKetoprofen 5% Topical Gel

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Tea Tree Oil 5%/DMSO Topical Solution

Add

Adding

Radio 3

CheckboxKetoconazole 100 mg Capsules

Add

Adding

Radio 3

CheckboxKetoconazole 6% Nail Solution

Add

Adding

Radio 3

CheckboxKetoconazole 300 mg Capsules

Add

Adding

Radio 3

CheckboxKetoprofen 0.4% Iontophoresis Solution

Add

Adding

Radio 3

CheckboxKetoconazole 6%/DMSO Nail Solution

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Salicylic Acid 3% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 2%/Lidocaine 2%/Misoprostol 0.0024%/Phenytoin 2%/Aloe Vera 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 2%/Lidocaine 2%/Phenytoin 2%/Misoprostol 0.0024%/Urea/Aloe Vera Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 2%/Lidocaine HCl 2%/Phenytoin 2%/Misoprostol 0.0024%/Aloe Vera Oral Adhesive Paste

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Urea/DMSO Nail Suspension

Add

Adding

Radio 3

CheckboxKetoprofen 2%/Lidocaine 2%/Misoprostol 0.0024%/Phenytoin 2%/Aloe Vera Topical Gel

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Zinc Pyrithione 0.2%/Tacrolimus 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxKetoprofen 2%/Lidocaine 2%/Misoprostol 0.0024%/Phenytoin 2%/Aloe Vera 0.2% Topical Cream

Add

Adding

Radio 3

CheckboxKetoconazole 400 mg Capsules

Add

Adding

Radio 3

CheckboxKetoconazole 200 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxKetoprofen 2%/Lidocaine 2%/Aloe Vera 0.2%/Phenytoin 2% Topical Cream

Add

Adding

Radio 3

CheckboxKetoconazole 20 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxKetoconazole 100 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Clonidine HCl 0.2%/Lidocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Loperamide HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxKetoconazole 2%/DMSO Nail Solution

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Salicylic Acid 3%/Niacinamide 4% Topical Cream

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Diclofenac Sodium 3%/Baclofen 2%/Cyclobenzaprine HCl 2%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Ibuprofen 2% Topical Powder

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Betamethasone Valerate 0.1%/Zinc Pyrithione 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Nifedipine 10%/Gabapentin 6%/Pentoxifylline 5%/Lidocaine 3%/Prilocaine 3% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 30 mg/Diazepam 1 mg/Lidocaine HCl 30 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Nifedipine 2%/Clonidine HCl 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Lidocaine 3%/Nifedipine 2%/Piroxicam 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Diclofenac Sodium 3%/Baclofen 2%/Cyclobenzaprine HCl 2%/Bupivacaine HCl 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Lidocaine HCl 2%/Clonidine HCl 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoconazole 1%/Norfloxacin 1% Otic Gel (Vet)

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Loperamide HCl 7% Topical Gel

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Salicylic Acid 3% Topical Cream

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Salicylic Acid 2%/Clobetasol Propionate 0.05%/Zinc Pyrithione 0.2% Topical Cream

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Lidocaine 5%/Baclofen 2%/Cyclobenzaprine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Miconazole Nitrate 2%/DMSO Nail Solution

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Betamethasone 0.05% Topical Solution

Add

Adding

Radio 3

CheckboxKetoconazole 2%/Miconazole 2%/Clotrimazole 1% Topical Cream

Add

Adding

Radio 3

CheckboxKetoconazole 1% Otic Solution

Add

Adding

Radio 3

CheckboxKetamine HCl 30% Topical Gel

Add

Adding

Radio 3

CheckboxKetoconazole 2% Nasal Spray

Add

Adding

Radio 3

CheckboxKetamine HCl 7.5%/Gabapentin 10%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Lidocaine HCl 5%/Diazepam 1% Vaginal Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Diclofenac Sodium 8%/Gabapentin 6%/Baclofen 2%/Cyclobenzaprine HCl 2%/Bupivacaine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Gabapentin 10%/Clonidine HCl 0.2%/Baclofen 2% Topical Cream

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Amitriptyline HCl 5%/Baclofen 2%/Lidocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Amitriptyline HCl 5%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 2% Vaginal Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Orphenadrine Citrate 5%/Diclofenac Sodium 3%/Cyclobenzaprine HCl 2%/Tetracaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 4%/Ketoprofen 10%/Lidocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Baclofen 2%/Cyclobenzaprine HCl 2%/Gabapentin 6%/Lidocaine 5% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Gabapentin 10%/Clonidine HCl 0.2%/Baclofen 2 % Topical Cream

Add

Adding

Radio 3

CheckboxKetamine HCl 3% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 1%/Naltrexone HCl 1% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Clonidine HCl 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Gabapentin 6%/Amitriptyline HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Gabapentin 10%/Clonidine HCl 0.2%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Phenytoin 5%/Mexiletine HCl 2%/Clonidine HCl 0.2%/Menthol 0.025% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 10%/Amitriptyline HCl 5% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine HCl 5%/Gabapentin 10%/Tizanidine HCl 0.2%/Baclofen 2% Topical Cream

Add

Adding

Radio 3

CheckboxKetamine 100 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxKetamine 100 mg Troche

Add

Adding

Radio 3

CheckboxKetamine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxKetamine 25 mg/Midazolam 3 mg/Ondansetron 2 mg Troche

Add

Adding

Radio 3

CheckboxKetamine 200 mg Troche

Add

Adding

Radio 3

CheckboxKetamine 100 mg Rapid Dissolve Tablet

Add

Adding

Radio 3

CheckboxKetamine 10 mg Capsules

Add

Adding

Radio 3

CheckboxKetamine 50 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxKetamine 0.4% Oral Rinse

Add

Adding

Radio 3

CheckboxKetamine 100 mg/ml Otic Suspension

Add

Adding

Radio 3

CheckboxKetamine 25 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxKetamine 10 mg Troche

Add

Adding

Radio 3

CheckboxKetamine HCl 0.5%/Diazepam 1%/Baclofen 2% Vaginal Gel

Add

Adding

Radio 3

CheckboxKetamine 50 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxKetamine 10 mg Troche

Add

Adding

Radio 3

CheckboxKetamine 200 mg Rapid Dissolve Tablet

Add

Adding

Radio 3

CheckboxKetamine 100 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxKetamine HCl 0.5%/Diazepam 1%/Baclofen 2% Vaginal

Add

Adding

Radio 3

CheckboxKetamine 100 mg/ml/Oxytocin 24 Units/ml Nasal Spray

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.