Prescription Request Form

Prescription Transfer Form

Switching pharmacies is easy.
Farmington Family Pharmacy Transfer Form
Upload a photo of your prescription bottle and fill out the form below, and our pharmacy team will handle the transfer for you.

Most transfers are completed the same day.

Don’t know the medication name? No problem — just upload a photo of the bottle.
Requested Date

MonthDayYear
Date
Patient's Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Patient's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Email Address
example@example.com
Patient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a Photo of Your Prescription Bottle

Cancelof
Pharmacy where the medication currently is
Pharmacy phone number

Prescribed Medicine

As soon as possible (almost out)Within a few daysJust moving prescriptions
Additional Comments
I authorize Farmington Family Pharmacy to contact my current pharmacy and transfer my prescriptions.
Terms and Conditions*
Signature*
Date Signed

MonthDayYear
Date
Should be Empty:

Prescription Transfer Form