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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

CheckboxDoxepin 25 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxDocusate Sodium 30 mg/ml Oral Syrup

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Adding

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CheckboxDoxepin 100 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxDoxepin HCl 0.5% Mouthwash

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Adding

Radio 3

CheckboxDoxycycline 30 mg Slow Release Capsules

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Adding

Radio 3

CheckboxDoxepin 50 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxDoxycycline 20 mg/Phenytoin 20 mg/Lidocaine HCl 10 mg/Misoprostol 0.024 mg Wound Care Capsules

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Adding

Radio 3

CheckboxDoxepin 10 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxDoxycycline 10 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxDocusate Sodium 283 mg/3.88 Gm Rectal Enema Solution

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Adding

Radio 3

CheckboxDoxycycline 10 mg/ml To 100 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxDoxycycline 40 mg Capsules (Gluten Free)

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Adding

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CheckboxDoxepin HCl 2% Topical Gel

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Adding

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CheckboxDoxycycline 30 mg/Clotrimazole 3 mg/Betamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxDoxepin 10 mg/ml Oral Solution (Gluten Free)

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Adding

Radio 3

CheckboxDoxepin HCl 0.5%/Naltrexone HCl 0.1% Topical Gel (Vet)

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Adding

Radio 3

CheckboxDocusate Sodium 50 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxDiphenylcyclopropenone 5% Topical Cream

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Adding

Radio 3

CheckboxDiphenylcyclopropenone 2% Topical Ointment

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Adding

Radio 3

CheckboxDocusate Sodium 1% Oral Solution

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Adding

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CheckboxDiphenylcyclopropenone 0.01% Topical Solution

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Adding

Radio 3

CheckboxDiphenylcyclopropenone 1% Topical Solution

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Adding

Radio 3

CheckboxDipyridamole 25 mg Capsules (Gluten Free)

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Adding

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CheckboxDipyridamole 75 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxDipyridamole 10 mg/ml Oral Suspension

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Adding

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CheckboxDipyridamole 150 mg Capsules

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Adding

Radio 3

CheckboxDiphenhydramine HCl 100 mg Slow Release Capsules

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Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Naltrexone HCl 0.2% Topical Gel (Vet)

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Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Naltrexone HCl 0.5%/Vitamin D3 5000 Iu/Gm Topical Gel

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Adding

Radio 3

CheckboxDiphenhydramine HCl 25% Topical Gel

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Adding

Radio 3

CheckboxDiphenylcyclopropenone 0.1% Topical Solution

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Adding

Radio 3

CheckboxDocusate Sodium 2% Otic Solution

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Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Pramoxine HCl 1%/Hydrocortisone 1% Topical Gel

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Adding

Radio 3

CheckboxDisulfiram 250 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxDiphenhydramine HCl 3%/Lidocaine 3%/Hydrocortisone 2.5% Topical Cream

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Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Naltrexone HCl 0.5%/Vitamin D3 5000 Iu/Gm Topical Cream

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Naltrexone HCl 0.5% Topical Gel (Vet)

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Adding

Radio 3

CheckboxDiphenylcyclopropenone 2% Topical Solution

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Adding

Radio 3

CheckboxDisulfiram 125 mg Capsules

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Adding

Radio 3

CheckboxDipyridamole 50 mg Capsules (Gluten Free)

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Adding

Radio 3

CheckboxDocusate Sodium 14.1%/Benzocaine 1% Rectal Enema

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Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Camphor 3%/Menthol 1% Topical Cream

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Adding

Radio 3

CheckboxDiindolylmethane 6% Topical Cream

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Adding

Radio 3

CheckboxDiphenhydramine HCl 1%/Calamine 8% Topical Cream

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Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Hydrocortisone 0.5% Topical Cream

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Adding

Radio 3

CheckboxDiphenhydramine HCl 0.1%/Misoprostol 0.0024% Oral Rinse

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Adding

Radio 3

CheckboxDimercaptosuccinic Acid 250 mg Capsules

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Adding

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CheckboxDiphenhydramine HCl 2%/Hydrocortisone 1%/Aloe Vera 0.5% Topical Gel

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Adding

Radio 3

CheckboxDimercaptosuccinic Acid 100 mg Slow Release Capsules

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Adding

Radio 3

CheckboxDiphenhydramine HCl 2.5%/Diclofenac Sodium 2% Topical Gel

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Adding

Radio 3

CheckboxDiltiazem HCl 2% Topical Ointment

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Adding

Radio 3

CheckboxDiphenhydramine HCl 2.5 mg/ml/Nystatin 12,500 Units/ml/Hydrocortisone 0.25 mg/ml Mouthwash

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Hydrocortisone 1%/Aloe Vera 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxDimercaptosuccinic Acid 50 mg Slow Release Capsules

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Adding

Radio 3

CheckboxDimercaptosuccinic Acid 150 mg Slow Release Capsules

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Adding

Radio 3

CheckboxDiphenhydramine HCl 1%/Ketotifen 0.05% Topical Gel (Vet)

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Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Lidocaine HCl 1%/Dexamethasone Sodium Phosphate 0.05% Topical Spray

Add

Adding

Radio 3

CheckboxDimercaptosuccinic Acid 500 mg Capsules

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 2%/Hydrocortisone 1% Topical Cream

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 1%/Naltrexone HCl 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxDiphenhydramine HCl 1%/Dexamethasone Sodium Phosphate 0.05% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxDimercaptosuccinic Acid 200 mg Slow Release Capsules

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Adding

Radio 3

CheckboxDiphenhydramine HCl 1% Topical Ointment

Add

Adding

Radio 3

CheckboxDiltiazem 75 mg/ml Oral Suspension (Vet)

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 3 mg Slow Release Capsules

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 5 mg/Promethazine HCl 50 mg/Caffeine 100 mg Suppository

Add

Adding

Radio 3

CheckboxDiflorasone Diacetate 0.035%/Nystatin 30,000 U/Gm Topical Ointment

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 0.25% Nasal Spray

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Adding

Radio 3

CheckboxDiclofenac Sodium 50 mg Acid Resistant Capsules

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 2 mg/0.5 ml Topical Gel

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 2.5 mg/ml Nasal Spray

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Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Magnesium Chloride 5%/Cyclobenzaprine HCl 2%/Ibuprofen 2% Topical Gel

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Adding

Radio 3

CheckboxDiclofenac Sodium 50 mg Slow Release Acid Resistant Capsules

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 0.15% Nasal Spray

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Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Lidocaine 10%/Cyclobenzaprine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 50 mg Suppository

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 5 mg/Metoclopramide 5 mg Troche

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Adding

Radio 3

CheckboxDicloxacillin Sodium 250 mg/5 ml Oral Suspension

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Adding

Radio 3

CheckboxDihydroergotamine Mesylate 0.2% Topical Gel

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Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Guaifenesin 10%/Bupivacaine HCl 5%/Baclofen 2% Topical Gel

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Adding

Radio 3

CheckboxDiclofenac Sodium 20% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Lidocaine 10%/Cyclobenzaprine HCl 2% Topical Gel

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Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Ketamine HCl 10%/Gabapentin 6%/Verapamil HCl 6% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 75 mg Acid Resistant Capsules

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Adding

Radio 3

CheckboxDiazoxide 60 mg Capsules

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Adding

Radio 3

CheckboxDiazepam 10 mg/Gm Vaginal/Rectal Gel

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Adding

Radio 3

CheckboxDiazepam 10 mg/Gm Vaginal Gel

Add

Adding

Radio 3

CheckboxDiazoxide 50 mg Capsules

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Adding

Radio 3

CheckboxDiclofenac Sodium 5%/Gabapentin 5%/Amitriptyline HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Gabapentin 5%/Lidocaine 5%/Amitriptyline HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxDiazoxide 3% Topical Solution

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Adding

Radio 3

CheckboxDiclofenac Sodium 1.5%/Camphor 6%/Menthol 6% Topical Cream

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 3%/Lidocaine HCl 2%/DMSO 30% Topical Solution

Add

Adding

Radio 3

CheckboxDiazoxide 25 mg Capsules

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Adding

Radio 3

CheckboxDiclofenac Sodium 1.5%/DMSO 20% Topical Lotion

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Adding

Radio 3

CheckboxDiclofenac Sodium 10%/Gabapentin 5%/Lidocaine 5%/Amitriptyline HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 5%/Lidocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxDiazepam 15 mg/ml Rectal Gel (Vet)

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 5%/Gabapentin 6%/Magnesium Chloride 10%/Tizanidine HCl 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxDiazoxide 30 mg Capsules

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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