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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
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
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Diphenhydramine HCl 1 mg/mL/Lidocaine HCl 10 mg/mL/Misoprostol 0.024 mg/mL/Triamcinolone Acetonide 1.2 mg/mL Oral Rinse
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Diphenhydramine HCl 1 mg/mL/Lidocaine HCl 10 mg/mL/Misoprostol 0.024 mg/mL Oral Suspension
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Diphenhydramine HCl 1 mg/mL/Doxycycline Hyclate 2 mg/mL/Hydrocortisone 1.0 mg/mL Oral Suspension
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Dimethyl Sulfoxide 50% Topical Cream
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Dimethyl Sulfone 16% Nasal Solution
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Diltiazem HCl 50 mg/g Topical Gel
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Diltiazem HCl 12 mg/mL Oral Syrup
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Dihydroergotamine Mesylate 2 mg Slow Release (ME4M) Oral Capsules
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Dicyclomine HCl 10 mg/Doxylamine Succinate 10 mg/Pyridoxine HCl 10 mg Capsules
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Dihydroergotamine Mesylate 1 mg Troches
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Diclofenac Sodium 15 mg/mL Oral Suspension
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Diazepam 5 mg/Metoclopramide HCl 10 mg/Promethazine HCl 25 mg Suppositories
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Diazepam 1 mg/mL Rectal Gel
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Dextromethorphan HBr 40 mg/g/Diclofenac Na 80 mg/g/Piroxicam 40 mg/g Topical Cream
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Dextromethorphan HBr 10%/Guaifenesin 10%/Urea 8% Topical Gel
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Dexpanthenol 50 mg/mL/Piroxicam 5 mg/mL Topical Gel
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Dexpanthenol 50 mg/g Topical Gel Cream
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Dexpanthenol 5% Topical Gel
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Dexpanthenol 5% Nasal Spray
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Dexpanthenol 2.5%/Tretinoin 0.05% Topical Gel
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Dexamethasone Sodium Phosphate 5.28 mg/mL/Lidocaine HCl 40 mg/mL Solution for Iontophoresis
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Dexamethasone Sodium Phosphate 1.6 mg/mL/Verapamil HCl 1 mg/mL Solution for Iontophoresis
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Dexamethasone Sodium Phosphate 1.6 mg/mL/Lidocaine HCl 8 mg/mL/Verapamil HCl 1 mg/mL Solution for Iontophoresis
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Dexamethasone Sodium Phosphate 1.6 mg/mL/Lidocaine HCl 8 mg/mL Solution for Iontophoresis
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Dexamethasone Sodium Phosphate 1 mg/mL Solution for Iontophoresis
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Dexamethasone Sodium Phosphate 0.2%/Tetracycline HCl 2.4% Periodontal Gel
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Dexamethasone Sodium Phosphate 0.2%/Metronidazole Benzoate 10% Periodontal Gel
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Dexamethasone Sodium Phosphate 0.05%/Diphenhydramine HCl 1%/Quinine Sulfate 0.1% Topical Gel
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Dexamethasone 5 mg/Diphenhydramine HCl 25 mg/Metoclopramide HCl 20 mg Suppositories
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Dexamethasone 4 mg/mL/Lidocaine HCl 20 mg/mL Ultrasound Gel
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Dexamethasone 4 mg/mL Solution for Iontophoresis
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Dexamethasone 20 mg/mL/Piroxicam 1 mg/mL Topical Gel
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Dexamethasone 10 mg/mL/Piroxicam 1 mg/mL Topical Gel
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Dexamethasone 10 mg/Diphenhydramine HCl 25 mg/Metoclopramide HCl 20 mg Suppositories
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Dexamethasone 10 mg/Diphenhydramine HCl 25 mg/Haloperidol 1 mg/Metoclopramide HCl 20 mg Suppositories
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Dexamethasone 1.5%/Lidocaine HCl 4% Ultrasound Gel
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Dexamethasone 1.2%/Diphenhydramine HCl 2.4%/Haloperidol 0.1%/Lorazepam 0.1%/Metoclopramide HCl 2.4% Topical Gel
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Dexamethasone 1 mg/g Topical Cream
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Dexamethasone 0.4% Ultrasound Gel
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Dexamethasone 0.25 mg/2.5 mL/Tacrolimus 0.25 mg/2.5 mL Oral Suspension
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Dexamethasone 0.1%/Hydroquinone 5%/Retinoic Acid 0.1% Topical Ointment
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Dexamethasone 0.04% Topical Spray
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Deoxy-D-glucose 2 mg/g/Xylitol 50 mg/mL Nasal Solution
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Deoxy-D-glucose 2 mg/g/Lidocaine HCl 50 mg/mL Topical Cream
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Dehydroepiandrosterone 25 mg/Pregnenolone 20 mg Capsules
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Dehydroepiandrosterone 25 mg/mL Topical Gel
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Dehydroepiandrosterone 25 mg Capsules
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Dehydroepiandrosterone 25 mg/2 g Topical Lotion
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Dehydroepiandrosterone 15 mg/Testosterone 2 mg Troches
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Dehydroepiandrosterone 10 mg Vaginal Suppositories
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Dehydroepiandrosterone 1%/Levocarnitine 2% Topical Cream
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Dapsone 15 mg/mL Oral Solution
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Dantrolene Sodium 5 mg/mL Oral Syrup
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Cyclosporine A 2%/Ketoprofen 2.5%/Phenylephrine HCl 0.1% Topical Cream
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Cyclosporine A 2% Topical Gel
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Clotrimazole 10 mg/mL/Tetracaine 10 mg/mL Otic Suspension
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Coal Tar 0.4% Topical Gel
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Clonidine HCl 1 mg/g Topical Gel
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Coal Tar 6%/Zinc Oxide 6% Topical Paste
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Citalopram HBr 20 mg/g Topical Cream
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Coal Tar Solution 0.5% Topical Gel
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Cyclosporine 20 mg/mL Ophthalmic Solution
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Coal Tar Solution 2%/Hydrocortisone 1.2% Topical Lotion
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Chlorambucil 0.5 mg Capsules
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Cyclobenzaprine HCl 5 mg/mL/Ketamine HCl 46 mg/mL/Ketoprofen 100 mg/mL Topical Gel
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Cromolyn Sodium 50 mg/mL Oral Suspension
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Clopidogrel Bisulfate 5 mg/mL Oral Suspension
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Coenzyme Q10 200 mg Troches
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Clindamycin Phosphate 1.2%/Tretinoin 0.025% Topical Cream
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Cromolyn Sodium 4% Topical Cream
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Clonidine HCl 0.2%/Gabapentin 6%/Ketamine HCl 10% Topical Gel
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Cetirizine Dihydrochloride 10 mg/g Topical Cream
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Clonazepam 0.25 mg/2 mL Oral Gel
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Coal Tar Solution 2%/Salicylic Acid 5% Topical Cream
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Clotrimazole 2%/Ibuprofen 2%/Metronidazole 2%/Nifedipine 0.2%/Dexpanthenol 3% Topical Cream
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Chlorpromazine HCl 50 mg/mL Topical Spray
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Clindamycin HCl 22.7 mg/Clotrimazole 100 mg Vaginal Suppositories
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Cyclomethicone 10% Topical Lotion
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Clomipramine HCl 2.5 mg Capsules
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Coal Tar Solution 3%/Hydrocortisone 0.5% Topical Lotion
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Coenzyme Q10 50 mg Troches
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Cyclobenzaprine HCl 0.5%/Naproxen 10% Topical Gel
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Clotrimazole 10 mg/mL/Ketoconazole 22.2 mg/mL Nail Solution
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Clobetasol Propionate 0.5 mg/mL/Pyrithione Zinc 2 mg/mL Topical Gel
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Cyclophosphamide 25 mg Rectal Suppositories
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Clindamycin Phosphate 50 mg/mL Ophthalmic Solution
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Cevimeline HCl 30 mg/10 mL Oral Solution
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Ciprofloxacin 1% Otic Solution
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Clobetasol Propionate 0.05%/Pyrithione Zinc 2% Topical Spray
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Clotrimazole 1% Scalp Solution
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Clonazepam 0.2 mg/mL Mouthwash
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Chlorambucil 2 mg/mL Oral Syrup
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Clotrimazole 2%/Ibuprofen 2%/Metronidazole 2% Topical Powder
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Cyclobenzaprine HCl 20 mg/g Topical Gel
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Codeine Sulfate 15 mg Rectal Suppositories
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Chlorhexidine Gluconate 0.2% Oral Rinse
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Chlorpromazine HCl 25 mg Rectal Suppositories
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Cholestyramine 6.5% Topical Ointment
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Chloroquine Phosphate 500 mg Rectal Suppositories
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Clobetasol Propionate 0.5 mg/mL/Pyrithione Zinc 2 mg/mL Topical Lotion
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Directions:
QTY:
Refills
1
2
3
4
5
6
7
8
9
10
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Prescriber's Signature:
Date
3
Fill out the Pharmacy Name and Fax Number, then fax it to the Pharmacy.
Pharmacy Name
Pharmacy Fax Number
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