TRANSFER YOUR PRESCRIPTIONS

GEORGIES OUTPATIENT PHARMACY 6 EARLIN AVENUE, SUITE 130 BROWNS MILLS, NJ 08015 PHONE: 609-726-5800 FAX: 609-726-5810
TRANSFER FROM:
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Allergies with Medications? (Leave blank if none)
ANY OTHER FAMILY MEMBERS (Please add first name and last name)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter your phone number
PHARMACY INSURANCE INFO
Email
example@example.com
Transfer all of my prescriptions

YESNO JUST THE FOLLOWING
DO YOU WANT FREE DELIVERY?
Medicines to transfer (If not all)
I AUTHORIZE GEORGIES OUTPATIENT PHARMACY TO TRANSFER MY PRESCRIPTIONS.

Clear
DEAR PHARMACY, PLEASE TRANSFER THE ABOVE MENTIONED PATIENTS PRESCRIPTIONS TO:
GEORGIES OUTPATIENT PHARMACY 
6 EARLIN AVENUE, SUITE 130
BROWNS MILLS, NJ 08015
PHONE: 609-726-5800
FAX: 609-726-5810

A prescription may be transferred between pharmacies for the purpose of refill
dispensing by telephone, or by facsimile or electronic means as provided in N.J.A.C.
13:39-7.10 and 7.11. The transfer of a valid prescription between pharmacies, a pharmacy,
the registered pharmacist-in-charge, and the pharmacist who receives the request for
transfer shall immediately comply with the patient's request; “immediately” shall not exceed four hours.
Should be Empty: