Square Care Pharmacy - Transfer Prescription

* REQUIRED INFORMATION

FILL OUT THE FORM TO TRANSFER YOUR PRESCRIPTION.
NAME*

First NameLast Name
PHONE NUMBER*

Area CodePhone Number
E-MAIL
example@example.com
DATE OF BIRTH*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRESCRIPTION TO BE TRANSFERRED

If you would like to transfer all prescriptions, please select "Yes" below.
Transfer all prescriptions?*
If you would like to transfer only selected prescription(s) please enter them below.

LIST SPECIFIC PRESCRIPTION TO BE TRANSFERRED.
RX 1 MED NAME
ENTER MEDICATION NAME
RX 1 NUMBER
PRESCRIPTION NUMBER FROM CURRENT PHARMACY
RX 1 CURRENT PHARMACY NAME & CITY
RX 1 PHARMACY PHONE #
RX 2 MED NAME
ENTER MEDICATION NAME
RX 2 NUMBER
PRESCRIPTION NUMBER FROM CURRENT PHARMACY
RX 2 CURRENT PHARMACY NAME & CITY
RX 2 PHARMACY PHONE #
RX 3 MED NAME
ENTER MEDICATION NAME
RX 3 NUMBER
PRESCRIPTION NUMBER FROM CURRENT PHARMACY
RX 3 CURRENT PHARMACY NAME & CITY
RX 3 PHARMACY PHONE #
RX 4 MED NAME
ENTER MEDICATION NAME
RX 4 NUMBER
PRESCRIPTION NUMBER FROM CURRENT PHARMACY
RX 4 CURRENT PHARMACY NAME & CITY
RX 4 PHARMACY PHONE #
RX 5 MED NAME
ENTER MEDICATION NAME
RX 5 NUMBER
PRESCRIPTION NUMBER FROM CURRENT PHARMACY
RX 5 CURRENT PHARMACY NAME & CITY
RX 5 PHARMACY PHONE #
Comments for Pharmacy
Referred by:
If you have been referred here please let us know.
By submitting your phone number through this form, you consent to receive communications from us via phone calls, text messages, and other electronic means. Your phone number will be used only for the purposes of your services with our pharmacy.

You may withdraw your consent at any time by contacting us at: (360) 583-4633
Should be Empty: