Transfer Request Form

Transfer Request Form
Transfer Prescriptions to Lark Drugs Pharmacy

Note: If you have chronic opioid therapies call us at (707) 869-9055
Note: This form needs to filled out for each family member/individual due to privacy laws, safety concerns and accuracy.
Patient Name*

First NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of Birth*

MonthDayYear
Date
Patient Cell Phone Number*
Please enter a valid phone number.
Patient Home Phone Number (if same as cell, please enter the number again)*
Please enter a valid phone number.
How would you like to be contacted when prescriptions are ready for pick-up?*

Text message to cell phone numberCall to cell phone numberCall to home phone numberMail/Delivery (Pharmacy will contact you. Small fee may apply.)
What is the name and phone number of your current pharmacy? List all pharmacies that you use if more than one.*
Please list all of the medications you would like to have transferred to our pharmacy.*
Please list all of the medications you need filled in the next 3 days. If none, write none. If some medications are needed sooner, please call the pharmacy at (707)869-9055. All others will be put on hold for you to contact our pharmacy when refills are needed. *
Please list your primary care provider and all other routine providers who write prescriptions for you.
Please provide your insurance carrier
Please provide the primary cardholder ID number from your insurance card.
Please provide the BIN and PCN numbers from your insurance card.
Are you interested in our medication synchronization and autofill program to make your visit to our pharmacy more efficient and/or save money on mail/delivery?

YesNoPlease provide me information on this program with my next prescription pick-up
Are you currently using nicotine products?

Yes, and I would like to discuss quit options with the pharmacist.Yes, and I am not ready to quit.No
Go to kickitca.org for resources and help quitting nicotine products.
Are you interested in learning what vaccinations you may be eligible to receive?

Yes, please provide me a pharmacist recommendation with my next prescription pick-up.No
Should be Empty:

Transfer Request Form

Transfer Prescriptions to Lark Drugs Pharmacy