Patient Profile Transfer Request

Patient Profile Transfer Request

To transfer your prescriptions and medical information to Park Ridge Pharmacy, you'll need to provide your current pharmacy's information, including its name, address, and phone number. You'll also need to provide your personal information (name, date of birth, etc.) and details about your medications (name, dosage, prescription number). Finally, you'll need to complete a HIPAA release form authorizing the transfer of your medical information. Please fill out the form below to request the transfer of your patient profile, prescriptions, and medical history from your current pharmacy to Park Ridge Pharmacy.
Full Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Current Pharmacy Name and Contact Details*
Current Pharmacy Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
List of Prescriptions to be Transferred (if known)
Additional Medical History or Notes

HIPAA Authorization for Release of Medical Information