PRESCRIPTION TRANSFER REQUEST
Would you like to transfer prescriptions filled at a different pharmacy to Chet Johnson Drug? Complete this form and we'll take care of the rest!
Attention patients transferring prescriptions from Balsam Lake Pharmacy.
We would be happy to fill your prescriptions for you going forward, however, we are no longer able to directly transfer your profile from Balsam Lake Pharmacy. Therefore, we request that you call your Doctor and ask them to send new prescriptions for all your medications to Chet Johnson Drug in downtown Amery. Thank you!
Name
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Pharmacy to contact for prescription transfer(s)
Pharmacy Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.
Enter Information for each prescription to transfer.
Prescription number, drug name, strength
Is there anything that needs to be filled now?
Submit
Should be Empty: