Prescription Transfer

TRANSFER FROM

Pharmacy Name:

Pharmacy Phone Number:

PRESCRIPTIONS TO BE TRANSFERRED

If you choose to transfer only select prescriptions, please provide the drug name or prescription number for each one you'd like to transfer.

Transfer all my prescriptions

Only transfer my selected prescriptions:

PATIENT INFORMATION

First Name

Last Name

Email

Birth Date

Phone

I consent to sending this information to the pharmacy selected above.

I understand that some prescriptions cannot be transferred. In that case, the pharmacist will contact you.

I would like to receive promotional e-mails.

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