About You
Thanks for transferring your prescription to Chinook Pharmacy & Variety! Let's start with some information about you.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
What best describes your gender?
*
Female
Male
Prefer not to say
Is your gender the same sex you were given at birth?
*
Yes
No
Prefer not to say
Allergies
*
If no allergies type "none".
Medical Conditions
*
If no medical conditions please type "none".
Preferences
*
Easy Open
Visually Impaired
Hearing Impaired
Do Not Phone
None of the Above
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About Your Medications
Now, please tell us about your prescription and current pharmacy.
What is the name of the pharmacy from which you wish to transfer your prescription?
*
What is the pharmacy's phone number?
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please choose one of the following:
*
I want to enter medications by name
Skip to profile transfer request
Medication #1 Name and Strength
If you do not have any refills remaining at your prior pharmacy please contact you prescriber to send us a new order.
How would you like us to proceed once your prescription(s) is transferred to our pharmacy?
*
Prepare the medication
Place it on file and I will request it when needed
Please choose one of the following
I want to enter another medication for transfer
I’m all done
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Medication #2 Name and Strength
If you do not have any refills remaining at your prior pharmacy please contact you prescriber to send us a new order.
How would you like us to proceed once this prescription is transferred to our pharmacy?
Prepare the medication
Place it on file and I will request it when needed
Please choose one of the following
I want to enter another medication for transfer
I’m all done
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Medication #3 Name and Strength
If you do not have any refills remaining at your prior pharmacy please contact you prescriber to send us a new order.
How would you like us to proceed once this prescription is transferred to our pharmacy?
Prepare the medication
Place it on file and I will request it when needed
Please choose one of the following
I want to enter another medication for transfer
I’m all done
Back
Next
Medication #4 Name and Strength
If you do not have any refills remaining at your prior pharmacy please contact you prescriber to send us a new order.
How would you like us to proceed once this prescription is transferred to our pharmacy?
Prepare the medication
Place it on file and I will request it when needed
Please choose one of the following
I want to enter another medication for transfer
I’m all done
Back
Next
Medication #5 Name and Strength
If you do not have any refills remaining at your prior pharmacy please contact you prescriber to send us a new order.
How would you like us to proceed once this prescription is transferred to our pharmacy?
Prepare the medication
Place it on file and I will request it when needed
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When your prescription(s) is ready, how would you like to be notified?
*
Text Me
Call Me
No need to notify me
Anything else you'd like to tell our staff?
*
If you have nothing else to tell us please type "none."
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