*WEBSITE: Prescription Transfer Form

TRANSFER YOUR PRESCRIPTIONS TO US

It's easy, just fill out the form below and let us do all the work!
First and Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
Street Address
City
State
Zip
Current Pharmacy Name
Current Pharmacy Phone Number
Format: (000) 000-0000.
Please list medication name AND/OR current Rx number
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
I hereby authorize the transfer of my prescriptions and medication records from my current pharmacy to my new pharmacy (Sierra Pharmacy). I understand that the current pharmacy may require a few business days to process this request and verify my information before completing the transfer.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: