Transfer Prescriptions Form
Tamarack Pharmacy
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
What best describes your gender?
Male
Female
Prefer not to say
Allergies
*
In 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
What is the name of the pharmacy from which you wish to transfer your prescription(s)?
*
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 want to enter medications by name.
Back
Next
Medication #1 Name and 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
Back
Next
Medication #2 Name and 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
Back
Next
Medication #3 Name and 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
Back
Next
Medication #4 Name and 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
Back
Next
Medication #5 Name and 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.
Back
Next
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?
Submit
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