Prescription Transfer Request

* Indicates a required field

Use this Form to Request Refills to be Transferred from another Pharmacy.

Found in section

Review Patient Information

* Contact Phone Number Note: The pharmacist may contact you if there is a problem with your refill request.

Note: Please specify the patient's first and last name in the fields below.

* First Name

* Last Name

* Date of Birth (mm/dd/yyyy)

Transfer the Following Prescription(s)

Prescription 1

Prescription Number

* Drug Name

* Quantity

Doctor's First Name

Doctor's Last Name

Doctor's Phone Number

Allow Generic

Put on File (do not fill)

Prescription 2

Prescription Number

* Drug Name

* Quantity

Doctor's First Name

Doctor's Last Name

Doctor's Phone Number

Allow Generic

Put on File (do not fill)

Prescription 3

Prescription Number

* Drug Name

* Quantity

Doctor's First Name

Doctor's Last Name

Doctor's Phone Number

Allow Generic

Put on File (do not fill)

From This Pharmacy

* Pharmacy's Name

* Pharmacy's Phone Number

NOTICE: State or federal restrictions may apply to the transferring of prescriptions for controlled drugs and/or prescriptions for patients with Medicaid benefits. Please contact your Pharmacist if you have questions about transferring your prescriptions.

Receiving Your Prescription

When do you want to pick up your prescription?

Next Business Day
As Soon As Possible

Select the Pharmacy where Prescription was filled

Choose one of the following options.

Select from a list of pharmacies:

Search by phone number

Search by Location , Loads a new pharmacy location search form