Prescription Transfer Request
If you would like to transfer your prescriptions from your current pharmacy to Highland Health Providers' pharmacy, Highland Health Rx, please complete this form. Please note, in most cases, prescriptions for controlled substances cannot be transferred and will require a new prescription to be issued from your provider.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
What is the name and location of the pharmacy you currently use?
*
Phone Number of Preferred Pharmacy?
Please enter a valid phone number.
Please list the name(s) of your prescription(s) that you wish to transfer.
*
Submit
Should be Empty: