Existing Patient Medication Transfer Form
Please complete this form so that we may serve you better. Please complete one form for each family member.
Full Name
Date of Birth
/
Month
/
Day
Year
Date
Address
Primary Phone Number
Is this a
Home Phone
Cell Phone
Work Phone
Tribal Member?
Yes
No
Ho-Chunk Employee?
Yes
No
Text message notification when prescription is ready
Yes
No
Current Pharmacy Information:
What is your current pharmacy information (if you have more than one, please list)
Pharmacy name
Address
Phone number
Add another Pharmacy?
Yes
No
Pharmacy name
Address
Phone number
How would you like to obtain your prescriptions?
Pick up at House of Wellness Pharmacy in Baraboo
Pick up at Health Care Center Pharmacy in Black River Falls
Mail (if you are a non-tribal member, please contact the pharmacy to provide payment information for copays)
Medications to Transfer
Medication
Current Pharmacy
Rx#
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Current Pharmacy
Rx#
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Current Pharmacy
Rx#
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Current Pharmacy
Rx#
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Current Pharmacy
Rx#
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Current Pharmacy
Rx#
Fill now:
Yes
No
Add another medication?
Yes
No
Medication
Current Pharmacy
Rx#
Fill now:
Yes
No
Any Notes to the Pharmacy?
Submit
Should be Empty: