Prescription Transfer Screen 
  This form should be used when:

Related Pages:
 

  • You have a prescription on file at another pharmacy but you want us to fill it for you.
  Purpose:
 
  • To transfer your prescription from your current pharmacy to our pharmacy to be filled
  • To set up the patient's medical history
  • To set up shipping and billing for this prescription
  • Click here for information explaining how this transfer service works.

 * Indicates required fields.  Other fields are optional 

*Patient Name

*Home Address

*Phones

HmWk Cel
*email address

*Male or Female?

*Non-child resistant container lids?

  If no selection is made, child-resistant lids will be used.
*Date of Birth

*Medication Allergies

*Current medications 

(not including ones being transferred)

(Indicate "none" if necessary)

*Medical Conditions or Chronic Diseases

(Indicate "none" if necessary)

Enter your Rx information from your other pharmacy's prescription bottle.  Click here to see how to find this information on your prescription bottle.

 * Indicates required fields.  Other fields are optional (but greatly appreciated) 

Prescription Information Pharmacy Information (from Rx label)
*Rx# *Pharmacy Name

*Medication 

& strength 

Pharmacy Address
Quantity City, State, Zip
Doctor Name *Pharmacy Phone#
*Are there refills left? Yes    No

Note: If no refills remain we will attempt to contact your doctor for additional refills.  A $5.00 fee applies regardless of the outcome.

 Hours Open (EST, PT, etc)
May refill by (date)? Days Open (M-F, Sat)
Doctor's Phone#

Special Instructions 
   

NOTE:  To submit more than one prescription, click the submit button below, then use your browser's back button to return to this screen to submit the next one.

Payment Information:

*Card Type
*Card Number
*CVV2
*Card Expiration

Shipping Information: 

*Ship to Address
*Ship to Address

*Ship to

City, State, Zip
*Delivery Service

   Click here for shipping info

Priority Mail not available for Controlled Drugs (2nd Day or Next Day Only)
Additional Comments or Details

 Click the Submit button... .