Medication Transfer From Another Pharmacy Request Ver 1.1

Lopez Island Pharmacy (360)468-2616 Fax (360) 468-3825

Prescription Transfer Request

rev: 07/20/2024 HIPAA Compliant ver 1.1

This form is used to request prescription medications that you have filled at another pharmacy and you wish Lopez Island Pharmacy to fill them.

Not ALL prescriptions are transferable from one pharmacy to another, some questions below will help you determine if we can transfer the prescription.

For us to transfer a prescription from another pharmacy the prescription in question MUST have refills that are available to you. In other words if you walked in the other pharmacy could they refill the prescription WITHOUT contacting the prescriber.

We will make every effort to get your medication from another pharmacy. Remember some pharmacies we attempt to contact can be hard to reach, if you have trouble reaching the other pharmacy we might too.

Mail-Order pharmacies are very hard if not impossible for us to contact, if you use a mail-order pharmacy you will find it easier to contact your Dr. and ask them to send a new prescription to us.

If you feel that reaching the other pharmacy is difficult you can always contact your Dr. to send a new prescrption to Lopez Island Pharmacy. Sometimes Drs. in other states will tell you they can't send a prescription out of their state.

There are very few reasons that an out of state Dr. can't send an Rx to us, it may be their policy but as we said there are very few reasons that they can't send a Rx to our pharmacy.

If you elect to call your Dr. please be clear that you want the prescription sent to:

Lopez Island Pharmacy

Lopez Island, WA

360-468-2616 (Voice) 360-468-3825 (Fax)

Most prescriptions from Dr.'s are sent electroncially to us and believe it or not there is a Lopez Pharmacy in Texas that sometimes gets prescriptions meant for Lopez Island Pharmacy.

Some offices out of force of habit will send your request to your old pharmacy so again be clear to have your request sent to Lopez Island Pharmacy.

We will need certain information in order for us to make sure you have what your need.

General Information

Required fields are marked with an asterisk (*).

Contact Information

You're responsible for entering the correct contact information, following applicable federal and state laws.

Name of the person for whom the medication is for * use this form for ONLY 1 person*

First NameLast Name

Birth Date?*

Date

Primary Phone Number*

Area CodePhone Number

Phone Type*

MobileLandline

Email

example@example.com

Other Information

Enter the Prescription Number(If Known), and the name of the medication, strength and the quantity you need for the transfer.

ONLY enter 1 medication(Unique Prescription) per line.

When you have entered all the information and all the prescriptions you need scroll to the bottom and press "Submit"

Avoid asking for a few days of medication, small quanties of medication will not be the least costly way to do a transfer. We can always give you less medication than the Dr. orders but if the Dr. ONLY sends small amounts we can't increase what we give you.

For example 10 tablets MAY cost as much as 30 or more tablets, we will do what is in your best interst..

You will get a large green check mark at the end of this form, if you don't get the green check mark you did something wrong.

Have you filled a prescription OR had a vaccination at Lopez Island Pharmacy within the past 2 years?

YesNoUnsure

If you have not filled a prescription or had a vaccination at Lopez Island Pharmacy within the past 2 years we will need you to fill out an online new patient form.

At www.lopezislandpharmacy.com Opt#1

or

On Line New Patient Form

Are you completely out of the medication(s) you need transferred to Lopez Island Pharmacy?

YesNo

When will you need the transferred medication, if you need multiple transfers enter the earliest date you will need at least one of the transfers.

Date

Name of the pharmacy we need to contact*

Enter the pharmacy we need call phone number.

Area CodePhone Number

Rx Needed #1 AND Name

Rx Needed #2 AND Quantity Needed

Rx Needed #3 AND Quantity Needed

Any other information you think we need?

If you are here visiting and your insurance does not allow a vacation override/early refill, for example if medication was left at home, would you like us to fill your medication off your insurance?*

YesNoMaybe, but please call me with pricing information firstN/A - Example, I am transferring medication back to Lopez Island Pharmacy