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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.

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Fax Order Forms

Fax order forms to prescribers.

Fax Number *

Make sure the fax number is valid.

Doctor Name *

Doctor's name to be shown on the cover sheet.

Attention

Who the fax is for.

RE:

The subject of the fax from previous conversation(s).

Comments

Any comments to add to the bottom of the cover page.

Checkbox 3

Order Form Title

Ingredients

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BLT

Benzocaine, Lidocaine, Tetracaine

Checkbox

Bio-Identical HRT Oral

Progesterone, Bi-Est, Tri-Est, Estradiol, Estriol

Checkbox

Bio-Identical HRT Topical

Progesterone, Bi-Est, Estradiol, DHEA

Checkbox

Bio-Identical HRT Vaginal

Estradiol, Estriol, Progesterone, DHEA

Checkbox

Candida Glabrata

Amphotericin-B

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Erectile Dysfunction Injections

Alprostadil, Papaverine, Phentolamine, Atropine

Checkbox

Erectile Dysfunction Orals

Sildenafil, Tadalafil, Vardenafil

Checkbox

Erectile Dysfunction Urethral Gels

Alprostadil, Papaverine, Phentolamine

Checkbox

Vaginal Atrophy / Dryness / Painful Intercourse

Estradiol, Estriol, DHEA

Checkbox

Vaginal Infections (Bacterial/Yeast/Combo/Viral)

Boric Acid, Nystatin, Metronidazole, Chlorhexidine

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Email Order Forms

Email order forms to prescribers.

Email Address *

Make sure the email is valid.

Doctor Name *

Doctor's name to be in the email.

Message

Checkbox 3

Order Form Title

Ingredients

Checkbox

BLT

Benzocaine, Lidocaine, Tetracaine

Checkbox

Bio-Identical HRT Oral

Progesterone, Bi-Est, Tri-Est, Estradiol, Estriol

Checkbox

Bio-Identical HRT Topical

Progesterone, Bi-Est, Estradiol, DHEA

Checkbox

Bio-Identical HRT Vaginal

Estradiol, Estriol, Progesterone, DHEA

Checkbox

Candida Glabrata

Amphotericin-B

Checkbox

Erectile Dysfunction Injections

Alprostadil, Papaverine, Phentolamine, Atropine

Checkbox

Erectile Dysfunction Orals

Sildenafil, Tadalafil, Vardenafil

Checkbox

Erectile Dysfunction Urethral Gels

Alprostadil, Papaverine, Phentolamine

Checkbox

Vaginal Atrophy / Dryness / Painful Intercourse

Estradiol, Estriol, DHEA

Checkbox

Vaginal Infections (Bacterial/Yeast/Combo/Viral)

Boric Acid, Nystatin, Metronidazole, Chlorhexidine

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The order forms were sent successfully.

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There was an error sending the order forms. The fax number may be invalid.