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Prescription Transfer
Do you wish to transfer your prescriptions to your Revive Pharmacy? Simply fill out the secure form below to send a transfer request. We'll take care of the rest!
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1
Choose a location
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Revive Lynnwood - 62 Ave SE
Revive RX Royal Vista Dr NW
Revive Pharmacy - Capitol Hill 20th Ave NW
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Please Select
Revive Lynnwood - 62 Ave SE
Revive RX Royal Vista Dr NW
Revive Pharmacy - Capitol Hill 20th Ave NW
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2
Prescriptions to be transferred
*
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If you choose to transfer only select prescriptions, please provide the drug name or prescription number for each one you'd like to transfer.
Transfer all my prescriptions
Only transfer my selected prescriptions:
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3
Only transfer my selected prescriptions:
Prescription Number or Drug Name
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4
Name
*
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First Name
Last Name
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5
Email
*
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example@example.com
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6
Birth Date
*
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-
Date
Year
Month
Day
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7
Phone Number
*
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Area Code
Phone Number
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8
I consent to sending this information to the pharmacy selected above.
YES
NO
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