Home
Prescribe
Your Order Form
Popular Order Forms
Formulas
Staff
Order Form w/ Formulas
Custom Order Form
Popular Order Forms
Formulas
Documents
Peptides
Assessments
Prescribers
Tutorials
Settings
My Account
Support
Log Out
1
Search for medications or formulations to prescribe.
2
Add it to
Your 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
My Account
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
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
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
Checkbox
Sodium Thiosulfate 20%/Zinc Oxide 20% Topical Ointment
Add
Adding
Radio 3
Checkbox
Salicyclic Acid 60% Topical Paste
Add
Adding
Radio 3
Checkbox
Pyrilamine Maleate 2.5% Topical Ointment
Add
Adding
Radio 3
Checkbox
Sodium Benzoate 500 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Sodium Hyaluronate 200 mg Oral Troches
Add
Adding
Radio 3
Checkbox
Pyrogallol 10% Topical Cream
Add
Adding
Radio 3
Checkbox
Rutin 200 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Sodium Benzoate 3 g/15 mL Oral Liquid
Add
Adding
Radio 3
Checkbox
Quetiapine Fumarate 10 mg/ml Gastric Tube Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 50% Topical Paste
Add
Adding
Radio 3
Checkbox
Salicylic Acid 4% Topical Foam
Add
Adding
Radio 3
Checkbox
Ramipril 2 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Sodium Benzoate 333.5 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Salicylic Acid 10% Topical Cream
Add
Adding
Radio 3
Checkbox
Sodium Thiosulfate 25% Topical Liquid
Add
Adding
Radio 3
Checkbox
Sodium Valproate 431 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Resorcinol 0.585%/Sulfur 4% Topical Lotion
Add
Adding
Radio 3
Checkbox
Sildenafil 50 mg Vaginal Suppository
Add
Adding
Radio 3
Checkbox
Pyridoxine HCl 25 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Sodium Hyaluronate 2% Topical Gel
Add
Adding
Radio 3
Checkbox
Spironolactone 12.5 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Sodium Chloride 2% Iontophoresis Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 40% Topical Liquid
Add
Adding
Radio 3
Checkbox
Ropinirole HCl 1 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Squaric Acid Dibutylester 2% Topical Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 70% Topical Paste
Add
Adding
Radio 3
Checkbox
Rivastigmine 2 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Selegiline HCl 30 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 2%/Trichloroacetic Acid 7% Topical Gel
Add
Adding
Radio 3
Checkbox
Selegiline HCl 0.5 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Sodium Butyrate 600 mM Rectal Enema Liquid
Add
Adding
Radio 3
Checkbox
Silver Sulfadiazine 1% Topical Liquid
Add
Adding
Radio 3
Checkbox
Scopolamine Hydrobromide 0.4 mg Oral Troche
Add
Adding
Radio 3
Checkbox
Sulfadiazine 400 mg/ml/Trimethoprim 80 mg/ml Equine Oral Liquid
Add
Adding
Radio 3
Checkbox
Sodium Valproate 500 mg/5 mL Oral Liquid
Add
Adding
Radio 3
Checkbox
Sucralfate 100 mg/ml Rectal Enema Liquid
Add
Adding
Radio 3
Checkbox
Pyridoxine HCl 50 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Ronidazole 250 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Salicylic Acid 5%/Spironolactone 5% Topical Cream
Add
Adding
Radio 3
Checkbox
S-Adenosylmethionine 200 mg/ml Oral Oil Liquid
Add
Adding
Radio 3
Checkbox
Selegiline HCl 2.50 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Sodium Thiosulfate 300 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Spironolactone 10% Topical Cream
Add
Adding
Radio 3
Checkbox
Sulfadiazine 100 mg/ml Oral Liquid (Vet)
Add
Adding
Radio 3
Checkbox
Ramipril 1 mg/ml Gastric Tube Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 5%/Urea 10% Topical Ointment
Add
Adding
Radio 3
Checkbox
Sodium Valproate 576 mg Rectal Suppository
Add
Adding
Radio 3
Checkbox
Sodium Metabisulfite 10 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Sodium Ascorbate 20% Topical Serum
Add
Adding
Radio 3
Checkbox
Salicylic Acid 4% Topical Cream
Add
Adding
Radio 3
Checkbox
Sodium Ascorbate 10% Topical Cream
Add
Adding
Radio 3
Checkbox
Ronidazole 10 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Riluzole 10 mg/ml Gastric Tube Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 60% Topical Ointment
Add
Adding
Radio 3
Checkbox
Quinidine sulfate 30 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Silver Sulfadiazine 0.5% Otic Liquid
Add
Adding
Radio 3
Checkbox
Spironolactone 10 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Sodium Valproate 288 mg/5 mL Oral Liquid
Add
Adding
Radio 3
Checkbox
Sildenafil 0.2% Otic Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 5% Topical Gel
Add
Adding
Radio 3
Checkbox
Sotalol HCl 10 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Pyrimethamine 0.5 g/Sulfadiazine 10 g/30 mL Oral Liquid (Vet)
Add
Adding
Radio 3
Checkbox
Salicylic Acid 10% Topical Ointment
Add
Adding
Radio 3
Checkbox
Salicylic Acid 15% Topical Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 1%/Sulfur 2% Topical Ointment
Add
Adding
Radio 3
Checkbox
Salicylic Acid 2% Topical Foam
Add
Adding
Radio 3
Checkbox
Spironolactone 5% Topical Lotion
Add
Adding
Radio 3
Checkbox
Scopolamine Hydrobromide 0.4 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Pyruvic Acid 50% Topical Liquid
Add
Adding
Radio 3
Checkbox
Selegiline hydrochloride 30 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Riboflavin 50 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Sodium Hyaluronate 1%/Tretinoin 0.1% Topical Serum
Add
Adding
Radio 3
Checkbox
Salicylic Acid 1%/Sulfur 2% Topical Shampoo
Add
Adding
Radio 3
Checkbox
Scopolamine Hydrobromide 0.2% Nasal Spray
Add
Adding
Radio 3
Checkbox
Sodium Valproate 5.75% Topical Liquid
Add
Adding
Radio 3
Checkbox
Sildenafil 1% Iontophoresis Liquid
Add
Adding
Radio 3
Checkbox
Pyridoxine HCl 20 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Quinidine Sulfate 200 mg Slow Release (MEM4) Oral Capsules
Add
Adding
Radio 3
Checkbox
Scopolamine Hydrobromide 0.4 mg/0.1 mL Transdermal Gel
Add
Adding
Radio 3
Checkbox
Quetiapine Fumarate 50 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Sertraline HCl 1.12 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Sucralfate 200 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 4%/Aluminum Cl 4% Topical Gel
Add
Adding
Radio 3
Checkbox
Selegiline HCl 1.25 mg Oral Capsules
Add
Adding
Radio 3
Checkbox
Sodium Citrate 90 mg/ml/Sodium Lauryl Sulfate 9 mg/ml Rectal Enema Liquid
Add
Adding
Radio 3
Checkbox
Spironolactone 5% Topical Cream
Add
Adding
Radio 3
Checkbox
Ramelteon 8 mg/5 mL Oral Liquid
Add
Adding
Radio 3
Checkbox
Sodium Chloride 4 mEq/mL Oral Liquid
Add
Adding
Radio 3
Checkbox
Sertraline 1.25 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 20%/Triamcinolone 0.1% Topical Ointment
Add
Adding
Radio 3
Checkbox
Squalane 25% Otic Drops
Add
Adding
Radio 3
Checkbox
Simvastatin 20 mg/5 mL Gastric Tube Liquid
Add
Adding
Radio 3
Checkbox
Salicylic Acid 1%/Sodium Thiosulfate 20% Topical Gel
Add
Adding
Radio 3
Checkbox
Resorcinol 15% Topical Cream
Add
Adding
Radio 3
Checkbox
Salicylic Acid 3%/Urea 20% Topical Lotion
Add
Adding
Radio 3
Checkbox
Sucralfate 4% Gastric Tube Site Paste
Add
Adding
Radio 3
Checkbox
Selegiline HCl 5 mg/0.5 g Transdermal Cream
Add
Adding
Radio 3
Checkbox
Sodium Ascorbate 10%/Glycolic Acid 10% Topical Serum
Add
Adding
Radio 3
Checkbox
Ribavirin 200 mg/ml Oral Liquid
Add
Adding
Radio 3
Checkbox
Sildenafil 20 mg Oral Troches
Previous
Next
Directions:
QTY:
Refills
1
2
3
4
5
6
7
8
9
10
x
Prescriber's Signature:
Date
3
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.