Transfer a Prescription to Purdy Cost Less Pharmacy
We're your neighbors and we're ready to help.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Prefer not to say
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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 Open
Visually Impaired
Hearing Impaired
Do Not Call
None Of The Above
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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 name
Transfer all my prescriptions - skip to profile transfer request.
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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 medication
Place 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 done
I'd like to enter another medication
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Medication #2 Name and Strength
*
How would you like us to proceed once Medication #2 prescription is transferred to our pharmacy?
*
Prepare the medication
Place 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 done
I'd like to enter another medication
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Medication #3 Name and Strength
*
How would you like us to proceed once Medication #3 prescription is transferred to our pharmacy?
*
Prepare the medication
Place 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 done
I'd like to enter another medication
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Next
Medication #4 Name and Strength
*
How would you like us to proceed once Medication #4 prescription is transferred to our pharmacy?
*
Prepare the medication
Place 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 done
I'd like to enter another medication
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Next
Medication #5 Name and Strength
*
How would you like us to proceed once Medication #5 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) are ready how would you like to be notified?
*
Text me
Call me
No need to notify me
Anything else you'd like to tell us?
*
If nothing - please write "none".
Submit
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