Prescription Transfer Form

Prescription Transfer Form

Please fill out the form below to request a prescription transfer.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Which best describes your gender?*

MaleFemalePrefer Not to Say
Allergies*
If none, type "none".
Medical Conditions*
If none, type "none".
Preferences*

Easy OpenVisually ImpairedHearing ImpairedDo Not CallNone of the Above
Pharmacy Name*
What is the name of the pharmacy from which you wish to transfer your medication
Pharmacy Phone Number*
Please enter a valid phone number.

Profile Request - Please choose one of the following*

I want to enter medications by nameSkip to a profile transfer request

Medication #1 Name and Strength
How would you like us to proceed once this prescription is transferred to our pharmacy?

Prepare the medicationPlace it on file and I will request it when needed.
All done? Please choose one of the following...

I want to enter another medication for transferI'm all done

Medication #2 Name and Strength
How would you like us to proceed once this prescription is transferred to our pharmacy?

Prepare the medicationPlace it on file and I will request it when needed.
All done? Please choose one of the following...

I want to enter another medication for transferI'm all done

Medication #3 Name and Strength
How would you like us to proceed once this prescription is transferred to our pharmacy?

Prepare the medicationPlace it on file and I will request it when needed.
All done? Please choose one of the following...

I want to enter another medication for transferI'm all done

Medication #4 Name and Strength
How would you like us to proceed once this prescription is transferred to our pharmacy?

Prepare the medicationPlace it on file and I will request it when needed.
All done? Please choose one of the following...

I want to enter another medication for transferI'm all done

Medication #5 Name and Strength
How would you like us to proceed once this prescription is transferred to our pharmacy?

Prepare the medicationPlace it on file and I will request it when needed.

When your prescription(s) is ready, how would you like to be notified?*

Call MeText MeNo Need to Notify Me
Anything else you'd like to tell our staff?
HIPAA Statement: Your Health Info & Your Privacy

At Modoc Family Pharmacy, your health information is personal—and we treat it that way. We follow all federal and state laws (like HIPAA) to keep it private and secure.

How We Use Your Info
We may use or share your information:

To treat you or fill your prescriptions
To bill your insurance
To improve our services
To remind you of appointments or offer helpful health options
We’ll always ask your permission before using your info for things like marketing or sharing certain sensitive records.

When We Share Without Asking
By law, we may share your info in special cases, like:

Emergencies
Public health reporting
Legal or court requests
Help with law enforcement, military, or organ donation
Serious safety risks

Your Rights
You have the right to:
Ask us not to share your info (we’ll follow if the law allows)
Get copies of your health records
Request changes to your records
Ask us to contact you at a specific address or number
Know who else we’ve shared your info with
Be told if there’s ever a breach of your information
Get a paper copy of this notice
Questions or Concerns?
If you have questions or feel your privacy rights were violated, contact us directly.

We may update this notice from time to time. The current version will always be available at our pharmacy.
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