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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

CheckboxDiclofenac Sodium 10%/Doxepin HCl 10%/Baclofen 2%/Bupivacaine HCl 2%/Nifedipine 2% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 1.3% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 4% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 10% Topical Gel

Add

Adding

Radio 3

CheckboxDiazoxide 50 mg/ml Oral Suspension (Vet) (Flavored)

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 3%/Cyclobenzaprine HCl 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxDiclofenac Sodium 5%/Lidocaine 2%/Prilocaine 2% Topical Gel

Add

Adding

Radio 3

CheckboxDiazepam 5 mg/Gm Vaginal

Add

Adding

Radio 3

CheckboxDiazepam 1%/Baclofen 2%/Lidocaine 5% Vaginal

Add

Adding

Radio 3

CheckboxDiazepam 10 mg Troche

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 30 mg Troche

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 60 mg Capsules

Add

Adding

Radio 3

CheckboxDiazepam 2% Topical/Rectal Cream

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 100 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 45 mg Capsules

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 20 mg/Oxycodone HCl 10 mg Capsules

Add

Adding

Radio 3

CheckboxDiazepam 5 mg/ml Rectal Gel

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 30 mg/Diphenhydramine HCl 25 mg Suppository

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 200 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 15 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxDiazepam 10 mg/Gm Vaginal Cream

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 60 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 30 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 100 mg Capsules

Add

Adding

Radio 3

CheckboxDiazepam 10 mg Suppository

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 200 mg Capsules

Add

Adding

Radio 3

CheckboxDiazepam 5 mg Suppository

Add

Adding

Radio 3

CheckboxDiazepam 2 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 30 mg Suppository

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 25 mg Troche

Add

Adding

Radio 3

CheckboxDiazepam 2.5 mg Troche

Add

Adding

Radio 3

CheckboxDextromethorphan Hydrobromide 2 mg/ml/Guaifenesin 20 mg/ml Oral Liquid

Add

Adding

Radio 3

CheckboxDiazepam 5 mg/Gm Rectal Gel

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 10 mg/5ml/Quinidine Sulfate 5 mg/5ml Oral Suspension

Add

Adding

Radio 3

CheckboxDexamethasone 2 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxDexamethasone 2%/Piroxicam 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 4 mg/Carbamazepine 200 mg Suppository

Add

Adding

Radio 3

CheckboxDexamethasone 0.5%/Diphenhydramine HCl 2%/Lidocaine HCl 1% Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 10 mg Suppository

Add

Adding

Radio 3

CheckboxDexamethasone 20 mg Suppository

Add

Adding

Radio 3

CheckboxDexamethasone 100 mg Suppository

Add

Adding

Radio 3

CheckboxDexapanthenol 3%/Clotrimazole 2%/Ibuprofen 2%/Metronidazole 2%/Nifedipine 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 1 mg/ml Oral Syrup

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 10 mg Capsules

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 10%/Guaifenesin 10% Gel

Add

Adding

Radio 3

CheckboxDexamethasone 0.075 mg/0.1 ml Topical Spray

Add

Adding

Radio 3

CheckboxDexamethasone 84 Mcg/0.1 ml Nasal Spray

Add

Adding

Radio 3

CheckboxDexamethasone 4 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxDexamethasone 4 mg Suppository

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 0.2% Oral Syrup

Add

Adding

Radio 3

CheckboxDextromethorphan HBr 1 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxDexamethasone 24 mg Suppository

Add

Adding

Radio 3

CheckboxDeoxy-D-Glucose 2%/Egcg 1% Topical Anhydrous Cream

Add

Adding

Radio 3

CheckboxDexamethasone 0.5 mg/0.1 ml Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 100 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxDesmopressin Acetate 0.033 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxDesonide 0.05% Otic Solution

Add

Adding

Radio 3

CheckboxDexamethasone 0.1%/Erythromycin 3% Dental Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 50 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 50 mg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 0.4% Ultrasound Gel

Add

Adding

Radio 3

CheckboxDeoxy-D-Glucose 0.2% Nasal Solution

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 150 mg Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 100 mg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxDexamethasone 0.1 mg/ml Oral Elixir

Add

Adding

Radio 3

CheckboxDesmopressin Acetate 1.5 mg/ml Nasal Spray

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 200 mg/5 ml Oral Suspension

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 100 mg Capsules

Add

Adding

Radio 3

CheckboxDexamethasone 0.1% In Isopropyl Myristate Base

Add

Adding

Radio 3

CheckboxDesoximetasone 0.25%/Zinc Pyrithione 0.2% Topical Spray

Add

Adding

Radio 3

CheckboxDeoxy-D-Glucose 0.29%/Ibuprofen 2% Topical Cream

Add

Adding

Radio 3

CheckboxDexamethasone 0.05 mg/ml Oral Rinse

Add

Adding

Radio 3

CheckboxDexamethasone 0.4% Iontophoresis Solution

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 0.35% Vaginal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 2.5 mg Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg Rapid Dissolve Tablet

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 13 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 3 mg/Gm Vaginal

Add

Adding

Radio 3

CheckboxDapsone 5% Topical Cream

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 13 mg/Gm Vaginal Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 3.25 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 10 mg/ml Sublingual Drops

Add

Adding

Radio 3

CheckboxDapsone 2 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 50 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg/ml Sublingual Drops

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 35 mg Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 13 mg/Gm Vaginal

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg Capsules

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxDapsone 8.5%/Spironolactone 5%/Niacinamide 2% Topical Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 15 mg/0.25 ml Topical Cream

Add

Adding

Radio 3

CheckboxDapsone 5%/Naltrexone HCl 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 25 mg Troche

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 5 mg Troche

Add

Adding

Radio 3

CheckboxDehydroepiandrosterone 12.5 mg Capsules

Add

Adding

Radio 3

CheckboxDapsone 5%/Niacinamide 4% Topical Cream

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 5% 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

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!

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