Rx Transfer Request

Prescription Transfer Request Form
Form Name
Hi! Thank you for wanting us to be a part of your healthcare team. We look forward to helping. Please complete the below information so that we can make the process as quick as possible.

You can also text/call us at 212-749-6626 or email us at Hi@ahmarx.com with any questions that you might have!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Best Contact Number:*
Please note we will be sending you text messages
E-mail
Please enter to receive tracking information for your rx delivery.
Current Pharmacy Name*
Current Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescription Number or Medication to Transfer*
This should be on your prescription label - it may say RX Number
Do you have additional prescriptions to transfer?
Prescription Number or Medication to Transfer (2)
Prescription Number or Medication to Transfer (3)
Prescription Number or Medication to Transfer (4)
Thank you! Once we transfer the prescriptions over to us, we'll reach out to you to schedule delivery. Feel free to text/call us at 212-749-6626 or email us at Hi@ahmarx.com with any questions.
Should be Empty:

Prescription Transfer Request Form