Welcome To RX ON U
Pharmacy Transfer Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Previous Pharmacy
*
Previous Pharmacy Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please let us know if you want to..... (CHOOSE AN OPTION BELOW)
*
Transfer all of my prescriptions
Just transfer the RX(s) that I enter below
Type the name(s) of the prescriptions that you would like us to transfer below ⬇️
*
Name of Insurance
*
Provide picture below
Photo of Insurance Card
*
Notes for the Pharmacy Staff
Signature
*
Submit
Submit
Should be Empty: