Transfer Request Form

Transfer Request Form
Transfer Prescriptions to Sebastopol Family Pharmacy

Note: The pharmacy is currently not accepting transfers for chronic opioid therapies.
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 medications are needed sooner, please call the pharmacy at (707)824-1876. 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. *
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 Sebastopol Family Pharmacy