Transfer Request

Transfer Request

Please complete the following form to get the prescription transfer process started
Are you currently a patient with us?*

YesNo

Do you have prescription insurance?*

YesNoCurrent Patient- Already on file
Primary Insurance

Insurance ProviderBINPCNCardholder IDRx Group
Secondary Insurance

Insurance ProviderBINPCNCardholder IDRx Group
Insurance Card Images (Front and Back)

Cancelof

Please provide as much of the following information as you can to help us provide an easy transition from your previous pharmacy.

Please note that it can take up to 2 days to process transfers. If there is a medication that you need urgently, please call us at 425-788-2644.
Who should we call for the transfers?*

Pharmacy Name

Phone Number

CityState / Province

Postal / Zip Code
How many prescriptions will need to be transferred from this pharmacy?
Please provide the medication names, strengths, and prescription number for each medication. *
This list allows us to verify we have received all of the transfers needed. If there is something that is unable to be transferred, we will reach out to you to let you know.
Are there any medications you need filled within the next 7 days? If so, please list them below. *
Any medications transferred that are not needed within the next week will be put on your pharmacy profile. When you are ready for them, give us a call to get the order started.
Is there an additional pharmacy we would need to contact for medication transfers?*

YesNo
Who should we call for the transfers?*

Pharmacy Name

Phone Number

CityState / Province

Postal / Zip Code
How many prescriptions will need to be transferred from this pharmacy?
Please provide the medication names, strengths, and prescription number for each medication. *
This list allows us to verify we have received all of the transfers needed. If there is something that is unable to be transferred, we will reach out to you to let you know.
Are there any medications you need filled within the next 7 days? If so, please list them below. *
Any medications transferred that are not needed within the next week will be put on your pharmacy profile. When you are ready for them, give us a call to get the order started.
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