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Rx Transfer : The Compounder
In order for us to know all that we need to know, ya know, fill out the info below.
Personal Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
Confirmation Email
If you are sending email through an AOL address, it will more than likely not be returned as our email host cannot reply to emails sent through an AOL address
Phone #
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Pharmacy Information:
Pharmacy Name
*
Pharmacy Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Prescription Number(s) From Current Pharmacy
Rx1. Rx2, etc.
Medication Name(s)
Medication Name(s)
Is there anything specific or special we should know about prior to contacting your current pharmacy?
For example: They're Packer fans...
Please verify that you are human
*
Submit
Should be Empty: