Transfer Prescription Form

Select Your Pharmacy Location: *

Are you a new patient? *

Yes

No

Contact Information & Preferences

First Name: *

Middle Name:

Last Name: *

Date of Birth: *

Gender: *

Mailing Address:

Street Address

Apartment, Suite, etc.

City

State/Province

Zip/Postal

Is your Mailing Address the same as your Home Address?

Yes

No

Home Address:

Street Address

Apartment, Suite, etc.

City

State/Province

Zip/Postal

Best phone number to contact you at?

May we leave a message at this number?

Would you like to receive a text message when your prescription is ready?

Yes

No

Please enter your cell phone number:

Would you like to receive an e-mail notification when your prescription is ready?

Yes

No

Please enter your e-mail address:

Would you like to receive your medications with a NON-Child Safety (easy open) cap?

Yes

No

Would you like to use our free MedSynch refill program, which groups your refills for pickup on the same day?

Yes

No

Insurance Information

Insurance Company:

Name of Policyholder:

RxBIN: *

PCN: *

Group: *

ID: *

Medications & Conditions

Do you have allergies to any medications? *

Yes

No

Please list which medications you're allergic to, and describe the type of reaction you experience:

Do you suffer from any chronic conditions?

Your Healthcare Provider

Primary Physician's Name:

Is anyone other than you authorized to pick up your medications?

Yes

No

Please list their names:

Emergency Contact Information

Name:

Phone Number:

Relationship:

Contact Information

First Name:

Middle Name:

Last Name:

Date of Birth:

Best phone number to contact you?

May we leave a message at this number?

Yes

No

Where are your prescriptions being transferred from?

Previous Pharmacy Name:

Pharmacy Contact Phone:

Pharmacy Location:

Prescriptions

Add or remove to list all of your relevant medication information

Prescription:

(Medication Name)

Rx Number:

(Optional)

Add Prescription Remove Prescription

Pickup & Delivery Options

Pickup Options

Pickup

Delivery

Special Arrangement

Delivery Address

Street Address

Apartment, Suite, etc.

City

State/Province

Zip/Postal

Please tell us how you'd like to receive your medications:

Special Notes

Any notes for the pharmacist?