Patient Transfer Prescription Form

Patient Transfer Prescription Form

Please complete the following HIPAA-secure form to submit a Transfer of your prescription.
Is this for a Pet Medication?*
Pet Patient Information

We love our pets! Please complete all the necessary information below and we will follow-up shorlty.
Pet Owner Name

First NameMiddle NameLast Name
Pet's Name
ArachnoidBirdCanineEquineFelineFishFowlGoatGuinea PigInsectsMammalReptileOther
Pet's Date of Birth

MonthDayYear
Date
Patient Information
Patient Name*

First NameMiddle NameLast Name
Patient Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number*

Area CodePhone Number
Patient Email*
example@example.com
YesNo
Patient Date of Birth*

MonthDayYear
Date
N/APhysicianEMTNurseParamedicsPolice OfficerFirefightersOther Law Enforcement
Prescription Information
Please sign me up for auto-refill.*
If you have authorized refills available, we will automatically process when your prescription is due.
Current Pharmacy Name
Enter the name of the pharmacy that we will contact to transfer your Rx.
Current Pharmacy Phone Number

Area CodePhone Number
Rx Number 1*
Enter your Prescription Number found on the label of your medication.
Medication Name 1
Type the name of the medication.
Rx Number 2
Enter your Prescription Number found on the label of your medication.
Medication Name 2
Type the name of the medication.
Rx Number 3
Enter your Prescription Number found on the label of your medication.
Medication Name 3
Type the name of the medication.
PriceUnsatisfactory ServicePharmacy IssuesOut of State ShippingOther
Delivery Options
Yes - Ship to Patient's Home AddressNo - Ship to Patient Temporary Address (Fill out below)No - Ship to Physician's OfficeNo - Patient Will Pick-Up
Patient Shipping Address If Different than Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2-Day Free ShippingRush Order - Ship or Pick-up Next Day (Must receive before 2 pm PST)
Any additional information you would like us to know?
Our patients are number 1! Please rate our service.

How are we doing?
FacebookTV InterviewLinkedInGoogle/Internet SearchInstagramPress Release/NewsTwitterPhysician ReferralFamily/FriendMail (Letter, Flyer, etc.)Existing PatientOther
YesNo
**You will need to contact your insurance carrier to ask about your benefit coverage of compound medications. Valor does not guarantee reimbursement by your insurance plan.
Thank you for completing the transfer prescription form. You may electronically submit the order to Valor Compounding Pharmacy by clicking "Submit" below.

A Customer Care Specialist will contact you shortly.
Please verify that you are human*
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