Transfer Prescription Form

Transfer a Prescription to Purdy Cost Less Pharmacy

We're your neighbors and we're ready to help.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemalePrefer not to say

Medical History

Tell us a bit about your medical history.
Medical Conditions*
If none please write "none".
Allergies*
If none please write "none".
Preferences*

Easy OpenVisually ImpairedHearing ImpairedDo Not CallNone Of The Above

Transferring Pharmacy

Please take a moment to tell us a bit about your old pharmacy.
What is the name of the pharmacy from which you wish to transfer your prescription?*
Pharmacy Phone Number*
Please enter a valid phone number.
If there is more than one pharmacy - please note that here.
If not please write "n/a".
Please Choose an Option*

I want to enter medications by nameTransfer all my prescriptions - skip to profile transfer request.

Medication #1
Medication #1 Name and Strength*
How would you like us to proceed once Medication #1 prescription is transferred to our pharmacy?*

Prepare the medicationPlace it on file and I will request it when needed
That's all the info need for the first medication - please choose an option to continue:*

I'm all doneI'd like to enter another medication

Medication #2 Name and Strength*
How would you like us to proceed once Medication #2 prescription is transferred to our pharmacy?*

Prepare the medicationPlace it on file and I will request it when needed
That's all the info need for the second medication - please choose an option to continue:*

I'm all doneI'd like to enter another medication

Medication #3 Name and Strength*
How would you like us to proceed once Medication #3 prescription is transferred to our pharmacy?*

Prepare the medicationPlace it on file and I will request it when needed
That's all the info need for the third medication - please choose an option to continue:*

I'm all doneI'd like to enter another medication

Medication #4 Name and Strength*
How would you like us to proceed once Medication #4 prescription is transferred to our pharmacy?*

Prepare the medicationPlace it on file and I will request it when needed
That's all the info need for the fourth medication - please choose an option to continue:*

I'm all doneI'd like to enter another medication

Medication #5 Name and Strength*
How would you like us to proceed once Medication #5 prescription is transferred to our pharmacy?*

Prepare the medicationPlace it on file and I will request it when needed

When your prescription(s) are ready how would you like to be notified?*

Text meCall meNo need to notify me
Anything else you'd like to tell us?*
If nothing - please write "none".
Should be Empty: