Transfer your prescriptions to Orchards
Fill out this form and we'll transfer your prescriptions from your old pharmacy within one day!
Patient legal name
*
First Name
Last Name
Preferred name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Non-binary
Phone number
*
Email
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have any drug allergies?
*
No drug allergies
Yes
Allergies:
*
List any drug allergies and your reaction (if known)
Your medications
Previous pharmacy name
*
Previous pharmacy phone number
*
Medications
*
List any medications you take, including over-the-counter products and supplements.
Are you due to have any medications filled now? Please list:
What made you decide to transfer to us today?
In-store
ENTERED IN STORE
Submit
Should be Empty: