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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

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

CheckboxCyclosporine 2%/Dexamethasone 0.1% Suspension (Vet)

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 1%/Guaifenesin 10%/Dextromethorphan HBr 10% Topical Gel

Add

Adding

Radio 3

CheckboxCyclosporine 1% Oil Ophthalmic Solution

Add

Adding

Radio 3

CheckboxCyclosporine 10 mg/ml Topical Gel

Add

Adding

Radio 3

CheckboxCyanocobalamin 1000 mcg Troche

Add

Adding

Radio 3

CheckboxCyclobenzaprine HCl 10 mg Troche

Add

Adding

Radio 3

CheckboxCyanocobalamin 1000 mcg/0.25 ml Topical Cream

Add

Adding

Radio 3

CheckboxCyanocobalamin 100 mcg Troche

Add

Adding

Radio 3

CheckboxCyanocobalamin 2000 mcg Troche

Add

Adding

Radio 3

CheckboxCyclophosphamide 20 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCyclophosphamide 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCyclosporine 20% Oral Solution (Vet)

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.07%/Urea 2% Topical Gel

Add

Adding

Radio 3

CheckboxCyclosporine 1% Oral Rinse

Add

Adding

Radio 3

CheckboxCyclosporine 10 mg/ml/Neomycin 3.5 mg/ml/Dexamethasone 1 mg/ml/Polymyxin B 10,000 U/ml Otic Suspension

Add

Adding

Radio 3

CheckboxCrotamiton 10% Topical Gel

Add

Adding

Radio 3

CheckboxCurcumin 250 mg Vaginal Suppository

Add

Adding

Radio 3

CheckboxCreatine Monohydrate 20% Oral Suspension

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.1% Topical Foam

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.07% To 1% Topical Cream

Add

Adding

Radio 3

CheckboxCromolyn Sodium 100 mg Capsules

Add

Adding

Radio 3

CheckboxCollagen 0.5%/Sodium Hyaluronate 0.05% Topical Under Eye Gel

Add

Adding

Radio 3

CheckboxCromolyn Sodium 4% Topical Cream

Add

Adding

Radio 3

CheckboxCromolyn Sodium 4% Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxCurcumin 140 mg/20 ml Rectal Enema

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxCromolyn Sodium 4%/Metronidazole 1%/Ivermectin 0.5% Topical Cream

Add

Adding

Radio 3

CheckboxCupric Sulfate 5 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxCromolyn Sodium 4% Vaginal Cream

Add

Adding

Radio 3

CheckboxCromolyn Sodium 4%/Naltrexone HCl 1%/Aloe Vera 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.07% Topical Cream

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.07%/Urea 2% Topical Cream

Add

Adding

Radio 3

CheckboxCromolyn Sodium 4% Topical Gel

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.07% Topical Gel

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.07%/Ketotifen 0.05% Topical Gel

Add

Adding

Radio 3

CheckboxCollagen 0.5%/Menthol 0.037% Facial Gel-Lotion

Add

Adding

Radio 3

CheckboxColchicine 0.6 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCromolyn Sodium 4%/Coenzyme Q-10 1%/Glutamine 1% Dental Gel

Add

Adding

Radio 3

CheckboxCromolyn Sodium 4%/Naltrexone HCl 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxCyanocobalamin 0.5% Intranasal Gel

Add

Adding

Radio 3

CheckboxCollagen 1% Antiwrinkle Topical Lotion

Add

Adding

Radio 3

CheckboxCoenzyme Q-10 2%/Lipoic Acid 3% Topical Cream

Add

Adding

Radio 3

CheckboxCodeine Phosphate 90 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxCoenzyme Q-10 8 mg/ml/Vitamin E Acetate 6.25 U/ml/Lipoic Acid 20 mg/ml Oral Pediatric Drops

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 20%/Salicylic Acid 5% Topical Paste

Add

Adding

Radio 3

CheckboxCoenzyme Q-10 100 mg/Lipoic Acid 250 mg/Acetylcysteine 250 mg/Vitamin D3 5000 IU Capsules

Add

Adding

Radio 3

CheckboxColchicine 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 25% Topical Gel

Add

Adding

Radio 3

CheckboxCoenzyme Q-10 1.6 mg/ml/Phytonadione 0.16 mg/ml/Tea Tree Oil Topical Emulsion

Add

Adding

Radio 3

CheckboxColchicine 0.2% Topical Gel

Add

Adding

Radio 3

CheckboxCoenzyme Q-10 30 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxCodeine Phosphate 10 mg Troche

Add

Adding

Radio 3

CheckboxColchicine 0.4 mg/5 ml Oral Syrup

Add

Adding

Radio 3

CheckboxColchicine 0.2 mg/ml Oral Solution

Add

Adding

Radio 3

CheckboxCodeine Phosphate 120 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 50%/Salicylic Acid 2.4%/Anthralin 0.25% Topical Lotion

Add

Adding

Radio 3

CheckboxCodeine Phosphate 30 mg Suppository

Add

Adding

Radio 3

CheckboxCodeine Phosphate 12.5 mg/5 ml Oral Syrup

Add

Adding

Radio 3

CheckboxCoenzyme Q-10 1.6 mg/ml/Phytonadione 0.16 mg/ml/Tea Tree Oil Topical Spray

Add

Adding

Radio 3

CheckboxColchicine 0.5 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxCodeine Phosphate 15 mg/Papaverine HCl 15 mg Capsules

Add

Adding

Radio 3

CheckboxCoenzyme Q-10 1% Oral Rinse

Add

Adding

Radio 3

CheckboxCodeine Phosphate 60 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Anthralin 1% Topical Ointment

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10% Topical Foam

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10%/Salicylic Acid 1% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10%/Salicylic Acid 6% Topical Oil Emulsion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Salicylic Acid 0.5% Topical Lotion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 6%/Salicylic Acid 6% Topical Ointment

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Salicylic Acid 5% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Zinc Pyrithione 0.8%/Clobetasol Propionate 0.05% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 6.25%/Aloe Vera 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 12%/Sulfur 4%/Salicylic Acid 2% Topical Ointment

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10%/Salicylic Acid 3%/Triamcinolone 0.1% Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 6%/Salicylic Acid 6%/Shea Butter Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 8% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 8% Topical Ointment

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10%/Salicylic Acid 2% Scalp Lotion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Anthralin 1% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 10% Topical Oil

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Salicylic Acid 3%/Fluocinonide 0.05% Topical Lotion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 5% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Salicylic Acid 3% Pearlescent Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 2% Topical Oil

Add

Adding

Radio 3

CheckboxClotrimazole 100 mg Suppository

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 3%/Hydrocortisone 0.5% Topical Lotion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 5%/Hydrocortisone 1% Topical Lotion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 2%/Hydrocortisone 1%/Iodoquinol 1% Topical Cream

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Mupirocin 1%/Betamethasone Acetate 0.025% Topical Lanolin Ointment

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 2%/Miconazole 2%/Selenium Sulfide 2%/Desonide 0.05% Shampoo

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 3%/Clioquinol 1%/Hydrocortisone 0.5% Topical Lotion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 4%/Salicylic Acid 3%/Sulfur 3% Topical Ointment

Add

Adding

Radio 3

CheckboxClotrimazole 2%/Ibuprofen 2%/Tea Tree Oil 1% Topical Gel

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 3%/Clioquinol 1%/Hydrocortisone 1% Topical Lotion

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 2.5%/Salicylic Acid 2%/Sulfur 2% Shampoo

Add

Adding

Radio 3

CheckboxClotrimazole 1%/Tea Tree Oil 54%/Undecylenic Acid 5%/Urea 5% Topical Cream

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 2% Shampoo

Add

Adding

Radio 3

CheckboxCoal Tar Topical Solution 48.5%/Benzocaine 2%/Salicylic Acid 1% Topical Solution

Add

Adding

Radio 3

CheckboxClotrimazole 1%/Hydrocortisone 1% Otic Solution

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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