Which best describes you?
I am an individual seeking to transfer my prescriptions to Sixth Avenue Pharmacy
I am a facility seeking to transfer my prescriptions to Sixth Avenue Long Term Care Pharmacy.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
What best describes your gender?
*
Female
Male
Prefer not to say
Allergies
*
If none, type "none".
Medical Conditions
*
if none, type "none".
Preferences
*
Easy Open Lids
Visually Impaired
Hearing Impaired
Text When Ready
Do Not Phone
None of the Above
Preferred Packaging
*
Blister Packs
Medisets
Vials
What is the name of the pharmacy from which you wish to transfer your prescription?
*
Pharmacy Location
Pharmacy Phone Number
If there is more than one pharmacy, please note below.
Please choose one of the following
I want to enter medications by name
Skip to profile transfer request
You have chosen the option to transfer all the prescriptions with refills available?
Please proceed with a general profile transfer of all active prescriptions.
I prefer to enter medications by name.
Medication #1 Name
*
Medication #1 Strength
Medication #1 Prescriber
How would you like us to proceed once this prescription is transferred to our pharmacy?
Prepare the medication
Place it on file and I will request it when needed
Please choose one of the following
I want to enter another medication for transfer
I’m all done
Medication #2 Name
Medication #2 Strength
Medication #2 Prescriber
How would you like us to proceed once this prescription is transferred to our pharmacy?
Prepare the medication
Place it on file and I will request it when needed
Please choose one of the following
I want to enter another medication for transfer
I’m all done
Medication #3 Name
Medication #3 Strength
Medication #3 Prescriber
How would you like us to proceed once this prescription is transferred to our pharmacy?
Prepare the medication
Place it on file and I will request it when needed
Please choose one of the following
I want to enter another medication for transfer
I’m all done
Medication #4 Name
Medication #4 Strength
Medication #4 Prescriber
How would you like us to proceed once this prescription is transferred to our pharmacy?
Prepare the medication
Place it on file and I will request it when needed
Please choose one of the following
I want to enter another medication for transfer
I’m all done
Medication #5 Name
Medication #5 Strength
Medication #5 Prescriber
How would you like us to proceed once this prescription is transferred to our pharmacy?
Prepare the medication
Place it on file and I will request it when needed
When your prescriptions 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 our staff?
We'll be in touch!
Thank you for reaching out to us. Please leave the above information and someone will reach out to you shortly to discuss your prescription needs.
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Welcome!
We're so glad you're considering working with Sixth Avenue Long Term Care Pharmacy. Use the fields below to send us resident information.
Facility Name
Patient Name
First Name
Last Name
Patient's DOB
-
Month
-
Day
Year
Date
Contact Name
First Name
Last Name
Contact Phone
Please enter a valid phone number.
Contact Email
example@example.com
Patient's Insurance Card - Front
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Patient's Insurance Card - Back
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Patient's Intake Form (if avilable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Patient's Med List (if separate from the above)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Nearly done ... click submit below
You're all done. Just click submit below to send us your transfer request. Our team will be in touch with questions if needed. Thank you!
Submit
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