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 shortly.
Pet Owner Full Legal Name

First NameMiddle NameLast Name
Pet's Name
Pet's Species

Other
Pet's Date of Birth

MonthDayYear
Date
Patient Information

Please complete the following fields so we may create a new patient profile for you, or add to your current account, if you're already a patient with us.
Patient Full Legal Name

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
Date
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
I would like to receive emails containing marketing, education, promotions, and/or information from Valor Compounding Pharmacy.
Are you a First Responder?
Prescriptions to Transfer Information

Please complete your prescription details so that we may request the transfer on your behalf.
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
Primary Prescriber Name

First NameLast Name
Clinic / Practice Name
Prescriber 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 Include name / strength / dosage form.
Rx Number 2
Enter your Prescription Number found on the label of your medication.
Medication Name 2
Type the name of the medication Include name / strength / dosage form.
Rx Number 3
Enter your Prescription Number found on the label of your medication.
Medication Name 3
Type the name of the medication Include name / strength / dosage form.
Reason For Transfer

Other
What is the reason you are transferring your prescription to Valor? (Check all that apply.)

Other
Delivery Options
Ship or Pick-Up?
Patient Shipping Address If Different than Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Ready / Ship Options
Any additional information you would like us to know?
Our patients are number 1! Please rate our service.

How are we doing?
How did you hear about us?

Other
Would you like us to provide an universal claim form with the package for possible reimbursement from your insurance company?
**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
'; var analyticsAutoLink = ''; (function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o), m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m) })(window,document,'script','https://www.google-analytics.com/analytics.js','ga'); ga('create', ' ', 'auto', {'allowLinker': true}); ga('send', 'pageview'); if(window.analyticsAutoLink && analyticsAutoLink != '') {analyticsAutoLink = analyticsAutoLink.replace(/ /g, '').split(/[,\n]/g);ga('require', 'linker');ga('linker:autoLink', analyticsAutoLink);}
Should be Empty:

Patient Transfer Prescription Form

Pet Patient Information

Patient Information

Prescriptions to Transfer Information