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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

CheckboxBrompheniramine Maleate 12 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxBromocriptine Mesylate 5 mg Capsules (Gluten Free)

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Adding

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CheckboxBudesonide 1 mg Troche

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Adding

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CheckboxBrompheniramine Maleate 8 mg Slow Release Capsules

Add

Adding

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CheckboxBrompheniramine Maleate 4 mg/Pseudoephedrine HCl 60 mg/Guaifenesin 300 mg Capsules

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Adding

Radio 3

CheckboxBoric Acid 750 mg/Chloramphenicol 750 mg/Hydrocortisone 10 mg Otic Insufflation Powder

Add

Adding

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CheckboxBrompheniramine Maleate 8 mg/Pseudoephedrine HCl 120 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxBudesonide 1 mg/5 ml Oral Slurry

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Adding

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CheckboxBoric Acid 2%/Phenol 1.89% (W/W)/Zinc Oxide 15% Topical Powder (Vet)

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Adding

Radio 3

CheckboxBoric Acid 600 mg Vaginal Suppository

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Adding

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CheckboxBromocriptine Mesylate 2.5 mg Capsules (Gluten Free)

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Adding

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CheckboxBoric Acid 30% Vaginal

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Adding

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CheckboxBudesonide 1 mg/0.1 ml Topical Cream (Vet)

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Adding

Radio 3

CheckboxBismuth Citrate 410 mg Capsules

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Adding

Radio 3

CheckboxBetamethasone Valerate 0.012%/Mupirocin 0.15% Topical Gel

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Adding

Radio 3

CheckboxBoric Acid 2.7% Alcoholic Otic Solution (Vet)

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Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.064%/Salicylic Acid 2% Topical Lotion

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Adding

Radio 3

CheckboxBetamethasone Valerate 0.12% Scalp Solution

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Adding

Radio 3

CheckboxBismuth Citrate 4.1% Oral Suspension

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Adding

Radio 3

CheckboxBetamethasone Dipropionate 0.05%/Urea 40%/Ammonium Lactate 7% Topical Cream

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Adding

Radio 3

CheckboxBetamethasone Valerate 0.008%/Mupirocin 0.15% Topical Cream

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Adding

Radio 3

CheckboxBoric Acid 1%/Menthol 3% Compound Topical Ointment

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Adding

Radio 3

CheckboxBismuth Citrate 205 mg Capsules

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Adding

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CheckboxBetamethasone Valerate 0.008%/Mupirocin 0.15% Topical Gel

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Adding

Radio 3

CheckboxBismuth/Potassium Citrate Oral Solution

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Adding

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CheckboxBetamethasone Valerate 0.12%/Lidocaine HCl 2% Topical Spray

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Adding

Radio 3

CheckboxBiotin 200 mg Capsules

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Adding

Radio 3

CheckboxBetamethasone 0.75 mg Capsules (For Nasal Irrigation/Nebulizer)

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Adding

Radio 3

CheckboxBiotin 5 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxBoric Acid 2.5%/Salicylic Acid 1%/Sulfur 1%/Camphor 0.333% Topical Lotion

Add

Adding

Radio 3

CheckboxBiotin 0.2% Scalp Spray

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Adding

Radio 3

CheckboxBismuth Ammonium Citrate Oral Solution

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Adding

Radio 3

CheckboxBethanechol Chloride 1 mg/ml To 5 mg/ml Oral Suspension

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Adding

Radio 3

CheckboxBiotin 0.2% Scalp Oil

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Adding

Radio 3

CheckboxBoric Acid 1%/Hydroxyquinoline Sulfate 0.026% Vaginal Jelly

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Adding

Radio 3

CheckboxBiotin 0.2% Topical Lotion

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Adding

Radio 3

CheckboxBetamethasone Valerate 0.1% Topical Foam

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Adding

Radio 3

CheckboxBiotin 100 mg/Ketoconazole 100 mg/Atropine Sulfate 2.5 mg Suppository

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Adding

Radio 3

CheckboxBenzyl Benzoate 25% Topical Lotion

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Adding

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CheckboxBenzoyl Peroxide 10%/Sulfur 5% Topical Lotion

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Adding

Radio 3

CheckboxBetahistine Dihydrochloride 4 mg Capsules

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Adding

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CheckboxBetahistine Dihydrochloride 8 mg Capsules

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Adding

Radio 3

CheckboxBetamethasone 0.025% Dental Rinse

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Adding

Radio 3

CheckboxBenzyl Alcohol 5% Topical Gel

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Adding

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CheckboxBenzyl Alcohol 20% Topical Gel

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Adding

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CheckboxBenzoyl Peroxide 14%/Zinc Oxide 72% Topical Paste

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Adding

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CheckboxBenzoyl Peroxide 20% Topical Gel

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Adding

Radio 3

CheckboxBetamethasone 0.042% Nasal Spray

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Adding

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CheckboxBetamethasone 0.05%/Salicylic Acid 3% Topical Ointment

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Adding

Radio 3

CheckboxBetamethasone 0.1% Nasal Solution

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CheckboxBetahistine Dihydrochloride 12 mg Capsules

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Adding

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CheckboxBenzoyl Peroxide 20% Topical Cream

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Adding

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CheckboxBenzyl Alcohol 5%/Tea Tree Oil 10%/Lavender Oil Topical Lotion

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Adding

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CheckboxBetamethasone 0.05%/Clotrimazole 1% Topical Cream

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Adding

Radio 3

CheckboxBeta Glucan 0.05%/Sodium Hyaluronate 1.2% Topical Solution

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Adding

Radio 3

CheckboxBetahistine Dihydrochloride 16 mg Capsules

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Adding

Radio 3

CheckboxBetamethasone 0.1%/Lidocaine 0.2%/Aloe Vera 0.5% Topical Gel

Add

Adding

Radio 3

CheckboxBetamethasone 0.6 mg/5 ml Oral Syrup

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Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Clindamycin 1% Clear Topical Gel

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Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Biotin 0.1%/Niacinamide 2% Topical Cream

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 7%/Niacinamide 2%/Biotin 0.1% Facial Gel

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Adding

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CheckboxBenzoyl Peroxide 10%/Clindamycin 2% Topical Cream

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Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Erythromycin 3% Topical Cream

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CheckboxBenzoin Tincture 8% Topical Ointment

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Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Niacinamide 2%/Spironolactone 2%/Clindamycin 1% Topical Gel

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Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Mupirocin 2% Facial Wash

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Adding

Radio 3

CheckboxBenzoyl Peroxide 7%/Niacinamide 2%/Biotin 0.1% Topical Cream

Add

Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Niacinamide 5%/Clindamycin 1% Topical Cream

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Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Tea Tree Oil 2.5% Topical Cream

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Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Urea 10% Face Wash

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Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Clindamycin 1% Topical Cream

Add

Adding

Radio 3

CheckboxBenzoic Acid 12%/Salicylic Acid 6% Topical Ointment

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Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Erythromycin 3%/Biotin 0.1% Topical Cream

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Adding

Radio 3

CheckboxBenzoyl Peroxide 5%/Erythromycin 3% Topical Cream

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Adding

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CheckboxBenzoyl Peroxide 10%/Erythromycin 3% Topical Gel

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Adding

Radio 3

CheckboxBenzoyl Peroxide 10%/Glycolic Acid 3% Topical Gel

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Topical Cream

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Adding

Radio 3

CheckboxBenzocaine 10%/Lidocaine 5%/Tetracaine 2% Topical Gel

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Topical Anhydrous Cream

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Adding

Radio 3

CheckboxBenzocaine 20% Otic Solution

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Iodoform 15.8%/Eugenol 13.7% Dental Paste

Add

Adding

Radio 3

CheckboxBenzocaine 10%/Lidocaine 5%/Tetracaine 2% Topical Cream

Add

Adding

Radio 3

CheckboxBenzocaine 165 mg/Zinc Oxide 170 mg/Benzalkonium Chloride 25 mg Suppository

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Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4%/Phenylephrine HCl 0.01% Topical Gel

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Adding

Radio 3

CheckboxBenzocaine 30%/Caffeine 0.4% Oral Gel

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Adding

Radio 3

CheckboxBenzocaine 15% Topical Gel

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Adding

Radio 3

CheckboxBenzocaine 20% Oral Adhesive Paste

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4%/DMSO Topical Cream

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Adding

Radio 3

CheckboxBenzocaine 25% Compound Dental Liquid

Add

Adding

Radio 3

CheckboxBenzocaine 25%/Capsicum Oleoresin 1%/Clove Dental Poultice

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Topical Gel

Add

Adding

Radio 3

CheckboxBenzoic Acid 2.5%/Aluminum Chlorohydrate 10%/Salicylic Acid 2.5%/Boric Acid 10% Foot Powder

Add

Adding

Radio 3

CheckboxBenzoic Acid 6%/Salicylic Acid 2.5%/Sulfur 4.6% Topical Ointment

Add

Adding

Radio 3

CheckboxBenzocaine 16.7% Dry Socket Paste

Add

Adding

Radio 3

CheckboxBenzocaine 20%/Lidocaine 6%/Tetracaine 4% Topical Ointment

Add

Adding

Radio 3

CheckboxBenzocaine 20% Topical Ointment

Add

Adding

Radio 3

CheckboxBenzocaine 0.47% Compound Oral Concentrate

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Adding

Radio 3

CheckboxBenzocaine 10% Topical Dental Solution

Add

Adding

Radio 3

CheckboxBenzocaine 10% Otic Solution

Add

Adding

Radio 3

CheckboxBenzocaine 2%/Camphor 0.5%/Menthol 0.5% Topical Gel (Zosil®) (Vet-Equine)

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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