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Print and fax it to the pharmacy at 401-284-4506.
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1
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
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Please ship to office
2
Prescriber and Prescription Information
Prescriber's First Name
Prescriber's Last Name
Phone Number
Fax Number
Address
City
State
ZIP
NPI/DEA
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Trichloroacetic Acid 20% Topical Cream
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Vancomycin 25 mg/ml Otic Liquid
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Verapamil HCl 15% Transdermal Gel
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Urea 8 % Topical Cream
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Zinc Sulfate 2.5% Topical Cream
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Tretinoin 10 mg/ml Gastric Tube Liquid
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Triamcinolone 0.1% Topical Cream
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Ursodiol 100 mg Oral Capsules
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Urea 30% Oral Liquid
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Theophylline 50 mg/ml Oral Liquid
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Testosterone 50 mg/g Transdermal Gel
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Topiramate 12.5 mg Oral Capsules
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Tacrolimus 0.03% Ophthalmic Drops
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Sulfasalazine 125 mg/ml Oral Liquid
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Theophylline 11 mg/0.1 mL Transdermal Gel
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Tizanidine 4 mg/5 mL Oral Liquid
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Tetracycline 5% Mouthwash Liquid
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Testosterone 25 mg/ml Transdermal Gel
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Tetracycline HCl 500 mg Rectal Suppository
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Topiramate 5 mg/ml to 40 mg/ml Oral Liquid
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Tacrolimus 0.15% Topical Ointment
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Tacrolimus 0.1% Topical Shampoo
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Theanine 250 mg Oral Capsules
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Tramadol HCl 20% Topical Gel
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Thyroid 150 mg Oral Slow Release (MEM4) Capsules
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Tramadol HCl 5 mg/ml Oral Liquid
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Thyroid 120 mg Oral Slow Release (MEM4) Capsules
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Tobramycin Sulfate 1% Otic Liquid
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Sumatriptan 100 mg Rectal Suppository
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Terbutaline Sulfate 2.5 mg/ml Oral Liquid
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Testosterone 200 mg/ml Topical Gel
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Sulfasalazine 500 mg Rectal Suppository
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Tacrolimus 0.05% Topical Ointment
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Tacrolimus 2 mg Rectal Suppository
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Tea Tree Oil 5% Topical Ointment
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Terazosin 0.5 mg/2 mL Oral Liquid
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Tramadol HCl 5% Topical Gel
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Theophylline 100 mg/5 mL Oral Liquid
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Tacrolimus 0.5 mg/ml Oral Liquid
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Tizanidine 2 mg/ml Oral Liquid
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Tetracycline HCl 3% Topical Ointment
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Sulfanilamide 15% Vaginal Cream
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Tacrolimus 0.1% Oral Rinse Liquid
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Tramadol HCL 5 mg/0.1 mL Transdermal Gel (Vet)
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Thiamine HCl 100 mg/ml Oral Liquid
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Testosterone 3 mg Vaginal Suppository
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Terbinafine HCl 2.5% Nail Liquid
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Sulfur 6% Topical Ointment
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Thioridazine HCl 100 mg Oral Capsules
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Sumatriptan 25 mg Rectal Suppository
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Temazepam 15 mg/5 mL Oral Liquid
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Terazosin 1 mg/ml Gastric Tube Liquid
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Tizanidine 2 mg/ml Topical Cream
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Tacrolimus 0.15% Topical Cream
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Theophylline 30 mg Slow Release (MEM4) Oral Capsules
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Thyroid 30 mg Oral Slow Release (MEM4) Capsules
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Sulfur 6% Topical Cream
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Testosterone 100 mg/ml Topical Gel
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Tacrolimus 1.5 mg Rectal Suppository
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Theophylline 25 mg/ml Oral Liquid
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Topiramate 6 mg/ml Oral Liquid
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Theophylline 5 µg/0.1 mL Nasal Spray
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Theophylline 25 mg/ml Gastric Tube Liquid
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Thymol 4% Topical Liquid
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Thyroid 97.5 mg Oral Slow Release (MEM4) Capsules
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Tetracycline HCl 5.4% Mouthwash Liquid
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Sumatriptan 50 mg Rectal Suppository
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Theanine 25 mg/0.1 mL Oral Spray
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Tacrolimus 1 mg Rectal Suppository
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Tetracycline HCl 125 mg Oral Capsules
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Tetracycline HCl 250 mg/5 mL Oral Liquid
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Testosterone 150 mg/ml Topical Gel
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Terbinafine HCl 2% Nail Liquid
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Terbinafine 50 mg/ml Oral Liquid
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Tetracaine HCl 0.5% Oral Rinse
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Tacrolimus 1 mg/ml Oral Liquid
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Tetracycline HCl 5% Topical Paste
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Thyroid 75 mg Oral Slow Release (MEM4) Capsules
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Tolterodine Tartrate 2 mg/5 mL Oral Liquid
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Tetracycline HCl 60 mg Oral Capsules
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Topiramate 25 mg Rectal Suppository
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Tacrolimus 2 mg/5 mL Rectal Enema Liquid
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Tacrolimus 0.1% Topical Foam
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Terbinafine 100 mg/ml Oral Liquid
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Theophylline 50 mg Slow Release (MEM4) Oral Capsules
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Tamoxifen Citrate 6 mg/ml Oral Liquid
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Sulfasalazine 50 mg/ml Oral Liquid
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Thyroid 60 mg Oral Slow Release (MEM4) Capsules
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Tramadol HCl 20 mg/0.1 mL Transdermal Gel (Vet)
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Thymol 3% Topical Liquid
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Tramadol hydrochloride 10 mg/ml Oral Liquid
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Tinidazole 50 mg/ml Oral Liquid
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Tea Tree Oil 5%/Terbinafine 2%/Undecylenic Acid 22.5% Topical Nail Lacquer
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Thyroid 90 mg Oral Slow Release (MEM4) Capsules
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Tadalafil 25 mg/ml Oral Sublingual Drops
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Tetracaine HCl 4% Topical Cream
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Temozolomide 420 mg/5 mL Oral Liquid
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Tobramycin 15 mg/ml Ophthalmic Liquid (Fortified)
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Testosterone 0.5 mg Vaginal Suppostories
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Succimer 250 mg Oral Capsules (DMSA)
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3
Fill out the Pharmacy Name and Fax Number, then fax it to the Pharmacy.
Pharmacy Name
Pharmacy Fax Number
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