Order Form Builder | Technician Dashboard | Bayview Pharmacy | Your Compounding Pharmacy of Choice

Home

Prescribe

Your Order Form

Compound Catalog Popular Order Forms

Staff

Compound Catalog

Order Form w/ Formulas

Custom Order Form Popular Order Forms Send Order Forms Documents Hospice SOPs Peptides Tests

Prescribers

Tutorials

Settings

My Account Support Log Out

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

Optimized for desktop use.
Please view on a larger screen to use this tool.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

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

CheckboxAmlodipine 0.5 mg/ml To 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 10 mg/0.1 ml Topical Cream (Vet)

Add

Adding

Radio 3

CheckboxAmmonium Chloride 400 mg/5 ml Oral Solution (Vet)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 50 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAmlodipine 10 mg Troche

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 75 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2.5%/Baclofen 2.5%/Gabapentin 2.5% Urethral Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Clonidine HCl 0.01% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Baclofen 2% Vaginal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Ketoprofen 2%/Carbamazepine 2% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Baclofen 2% Vaginal Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Gabapentin 6%/Lidocaine HCl 0.5% Oral Rinse

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Baclofen 2% Topical Cream

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Gabapentin 6%/Lidocaine HCl 2% Vaginal

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5 mg/0.1 ml Topical Gel (Vet)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Baclofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Carbamazepine 2%/Ketoprofen 2% Topical Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2%/Gabapentin 6% Vaginal/Rectal Gel

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 5 mg/0.1 ml Topical Cream (Vet)

Add

Adding

Radio 3

CheckboxAmantadine HCl 100 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAmantadine HCl 10 mg/0.1 ml Topical Cream (Vet)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 2.5%/Baclofen 2.5%/Gabapentin 2.5% Vaginal Cream

Add

Adding

Radio 3

CheckboxAmantadine HCl 50 mg/5 ml Oral Syrup (Gluten Free)

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 1 mg/ml Oral Syrup (Vet-Avian)

Add

Adding

Radio 3

CheckboxAluminum Sulfate 5%/Povidone 2% Topical Solution

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 1 mg/ml To 5 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxAmitriptyline HCl 0.25% To 5% Vaginal Cream

Add

Adding

Radio 3

CheckboxAmantadine HCl 20 mg/ml Oil Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 250 mg Capsules

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 1%/Stearic Acid 15% Topical Cream

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 16.8% Topical Ointment

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 1.74% Topical Paste

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 10.2 mg/ml/Lidocaine HCl 6.67 mg/ml/Nystatin 33,333 Units/ml Compound Mouthwash

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 61.4 mg/ml/Magnesium Hydroxide 20.6 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 64 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 80 mg/ml/Calcium Carbonate 8 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 10.2 mg/ml/Lidocaine HCl 6.67 mg/ml/Nystatin 33,333 Units/ml Compound Suspension For Mouthwash

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 12.78% Topical Ointment

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 115 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 200 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 64 mg/ml Oral Suspension (Vet)

Add

Adding

Radio 3

CheckboxAluminum Hydroxide 65 mg/Neomycin 17.5 mg/Methscopolamine Bromide 0.25 mg/Kaolin/Pectin Capsules (Vet)

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 5% Topical Powder

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 5% Topical Antiperspirant Cream

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 20% Topical Emollient Lotion

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 20% Topical Stick

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 20%/Aluminum Hydroxide 2% Topical Lotion

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 21.3% Dental Solution

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 7.7% Topical Paste

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 20% Topical Antiperspirant Stick

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 6.25% Topical Solution

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 10% Topical Solution

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 20% Topical Gel

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 8%/Aloe Vera Topical Gel

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 20% Topical Lotion

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 20% Topical Solution

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 10% Topical Antiperspirant Cream

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 35% Topical Solution

Add

Adding

Radio 3

CheckboxAluminum Chlorohydrate 12%/Aluminum Hydroxide 1.5% Topical Roll-On Lotion

Add

Adding

Radio 3

CheckboxAluminum Acetate Topical Solution

Add

Adding

Radio 3

CheckboxAlprostadil 100 mcg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 10mcg/ml/Papaverine HCl 30 mg/ml/Phentolamine Mesylate 1mg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAlprostadil 20 mcg/ml Injection Solution (Multi Dose Vial)

Add

Adding

Radio 3

CheckboxAlprostadil 20 Mcg/Gm Topical Gel

Add

Adding

Radio 3

CheckboxAluminum Chloride Hexahydrate 20%/Salicylic Acid 3% Topical Gel

Add

Adding

Radio 3

CheckboxAlprostadil 20 Mcg/0.4 ml Topical Gel

Add

Adding

Radio 3

CheckboxAlprostadil 0.2%/Arginine HCl 6%/Papaverine HCl 5% Topical Cream

Add

Adding

Radio 3

CheckboxAlprostadil 10 mcg/ml Injection Solution

Add

Adding

Radio 3

CheckboxAloe Vera Oil/Wheat Germ Oil Topical Cream

Add

Adding

Radio 3

CheckboxAluminum Acetate Topical Ointment

Add

Adding

Radio 3

CheckboxAluminum Acetate Otic Solution

Add

Adding

Radio 3

CheckboxAlbuterol 4 mg Slow Release Capsules

Add

Adding

Radio 3

CheckboxAllopurinol 20 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxAlbuterol 2 mg/5 ml Oral Syrup (Gluten Free)

Add

Adding

Radio 3

CheckboxAloe Vera 150 mg Suppository

Add

Adding

Radio 3

CheckboxAllopurinol 1 mg/ml Mouthwash

Add

Adding

Radio 3

CheckboxAlendronate 70 mg/75 ml Oral Liquid (Gluten Free)

Add

Adding

Radio 3

CheckboxAcylovir 2%/Ibuprofen 2%/Egcg 1%/Imiquimod 1%/Aloe Vera 0.2%/Deoxy-D-Glucose

Add

Adding

Radio 3

CheckboxAlbuterol 2 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAlbendazole 10% Topical Ointment

Add

Adding

Radio 3

CheckboxAloe Vera 100 mg Suppository

Add

Adding

Radio 3

CheckboxAlbuterol 4 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAllopurinol 10 mg/ml Oral Suspension (Vet-Avian)

Add

Adding

Radio 3

CheckboxAloe Vera Oil 2%/Vitamin E 200 Iu Suppository

Add

Adding

Radio 3

CheckboxAllantoin 1.5% Topical Gel (Zosil®) (Vet)

Add

Adding

Radio 3

CheckboxAlbendazole 200 mg/5 ml Oral Suspension

Add

Adding

Radio 3

CheckboxAllopurinol 10 mg/ml Oral Suspension

Add

Adding

Radio 3

CheckboxAcyclovir 200 mg Capsules (Gluten Free)

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Lidocaine 3% Topical Ointment

Add

Adding

Radio 3

CheckboxAcyclovir 7.5% Topical Cream

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Lidocaine 2%/Egcg 0.2% Lip Ointment

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Lidocaine HCl 5%/Deoxy-D-Glucose 2% Vaginal Gel

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Lidocaine HCl 2% Topical Gel

Add

Adding

Radio 3

CheckboxAcyclovir 333 mg Capsules

Add

Adding

Radio 3

CheckboxAcyclovir 100 mg Polyglycol Troche

Add

Adding

Radio 3

CheckboxAcyclovir 200 mg/5 ml Oral Suspension (Gluten Free)

Add

Adding

Radio 3

CheckboxAcyclovir 200 mg Popsicle

Add

Adding

Radio 3

CheckboxAcyclovir 5%/Lidocaine HCl 4%/Deoxy-D-Glucose 2% Topical Powder

Add

Adding

Radio 3

CheckboxAcyclovir 100 mg Vaginal Suppository

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.