Transfer Rx Form

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New Patient Intake Form / Prescription Transfer Form
**Make note of any special instructions regarding this prescription trtansfer in the NOTES text box located at the bottom of the form.**

Examples:
- Special container
- # days supply requested
- Preferred method of contact
Date Needed*
Is your transfer for a Person or Pet?*

PersonPet

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping address if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email
example@example.com
Prescription(s) to be transferred? Include the prescription ID number(s) if possible.*
Your prescription ID number(s) can be located on your label(s).
Name of your provider?*
Pharmacy and location we are transferring from? Include the phone number if possible.
Your prescription ID number(s) can be located on your label(s).
NOTES
A ProCompounding Representative will contact you by PHONE in 24-48 hours to confirm your transfer, verify your address, and collect medical and insurance information.
Should be Empty:

New Patient Intake Form / Prescription Transfer Form