Pharmacy Transfer Form
Forest Heights Pharmacy 4439 County Club Rd. Statesboro, Ga 30458 Phone: 912.489.7979.
Full Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date of Birth
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Please list your current pharmacy:
Do you authorize Forest Heights Pharmacy to contact your current Pharmacy to Transfer your refills?
*
Yes
No
Upload a copy of your current insurance card (optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please list your current medications you would like transferred: (optional)
Please list additional family members that you would like to have transferred as well: (optional)
Submit
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