Prescription Transfer Request
194-B Turkeysag Trail
Palmyra VA, 22963
JEFFERSON PHARMACY
PALMYRA, VA
EST. 2009
If you are a new patient hoping to transfer prescriptions from Rite-Aid Scottsville, please be aware that they are now closed, and we will no longer be able to obtain those. We would encourage you to reach out to your prescriber and have them send new prescriptions in directly to our pharmacy. Thank you!
Patient Name
*
DOB
*
Address
*
Phone Number
*
Format: (000) 000-0000.
Pharmacy to Transfer From
*
Pharmacy Phone Number
*
Format: (000) 000-0000.
Would you like all active prescriptions on file to be transferred to us and placed on hold? If you selected yes, you may proceed to the end of the form and submit
Yes
No
Please list all specific medications you would like transferred below
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
Drug Name and Strength
To be filled now or placed on file?
Fill now
Hold
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