Prescription Transfer Request

Request for Prescription Transfer

For patients wishing to transfer a prescription from another pharmacy to St. Paul Corner Drug
If you are currently filling prescriptions at another pharmacy and would like us to request those prescriptions be transferred to us, please provide that pharmacy's information below.

Because the transfer process can take multiple business days, if you currently have less than a one-week supply left of any medication, we recommend you get a refill at your current pharmacy before having us transfer that prescription.

Please note that we continue to have difficulty transferring prescriptions from chain pharmacies due to their staff shortages and other service issues. For this reason, we will only contact a chain or mail order pharmacy ONCE to request a prescription transfer; if that attempt fails, it will be your responsibility to request that your care provider send us a new prescription order(s) directly. We are not currently experiencing difficulty transferring prescriptions from independent pharmacies and are happy to do so.
Patient Information
Full name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Pharmacy Information

The pharmacy prescription(s) is/are being transferred from
Name*
Phone number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescription Information

Prescription(s) I would like transferred to St. Paul Corner Drug
Prescriber Information
Occasionally, a prescription that we attempt to transfer is out of refills or expired and therefore CANNOT be transferred. This is also true for prescriptions for controlled medications (e.g., opioids, stimulants). In these cases, we will contact the last provider by whom it was prescribed to get a new prescription order. Please include their contact information below.
Additional Comments
Is there anything else you'd like us to know about your transfer request?
Patient Attestation
By signing below, I attest that the information provided in this form is true and accurate to the best of my knowledge.
Signature of Patient (or Patient Representative)*

Powered by Jotform SignClear
Patient Representative (if signed by Patient Representative)

First NameLast Name
Relationship to Patient (if signed by Patient Representative)
Should be Empty:

Request for Prescription Transfer

Patient Information

Pharmacy Information

Prescription Information

Prescriber Information

Additional Comments

Patient Attestation