Gaughn's Prescription Transfer Request Form

Non-Urgent Prescription Transfer Request Form
Please complete the fields below to request a transfer of a prescription or complete medication profile from another pharmacy to Gaughn's Drug Store. Once the transfer is complete, we will contact you via phone to arrange for pick-up or delivery of the requested medications.

Please allow us 48 hours to complete this request.

If you require any prescriptions filled urgently, please contact the staff at Gaughn's Drug Store at 814.723.2840 and request your transfers via phone.

If you are a new patient to Gaughn's Drug Store, please complete the New Patient Enrollment Form on our website as well.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Please upload a photo of your insurance card. If you are unable to complete this step, please contact Gaughn's Drug Store at 814.723.2840 to provide your insurance information prior to picking up your transferred prescriptions.

Cancelof
Pharmacy Information
Name of pharmacy to contact for the transfer: Pharmacy Name*

Pharmacy Phone Number: Area Code*   Phone Number*

Pharmacy Location:   City*   State*
Complete Profile Transfer

Please transfer all available prescriptions from the above listed pharmacy (if checking this box you may omit the next section listing meds to transfer)
Total Number of prescriptions to be transferred Total Number of Rx
Medications to Transfer

Please list the medication(s) and/or prescription numbers that you would like to have transferred to Gaughn's Drug Store
Medication List:
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Should be Empty:

Non-Urgent Prescription Transfer Request Form

Pharmacy Information

Medications to Transfer