Transfer Your Prescription — Park Ridge Pharmacy

Transfer Your Prescription — Park Ridge Pharmacy

Park Ridge Pharmacy — 40 Park Ave, Unit 5, Park Ridge, NJ 07656
For controlled substances (such as Adderall, Xanax, Valium, or any pain medication), please call us directly at (201) 554-2200. Controlled substances cannot be transferred online.
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Pharmacy Name (where prescription is now)
Current Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medication Name to Transfer
This is the large bold text in the middle of your label. Example: Ibuprofen 200MG. It may also show the brand name in parentheses, such as (Generic for Motrin). Can't find it? Call us: (201) 554-2200
Prescriber/Doctor Name
Preferred Pickup Date at Park Ridge Pharmacy

MonthDayYear
Date
Preferred Pickup Time
Do you have more than one prescription to transfer?
Additional Medications to Transfer
Would you like delivery instead of pickup?
Delivery Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How did you hear about us?
Patient Signature
Additional Notes
By submitting this form, I authorize Park Ridge Pharmacy to contact my current pharmacy and transfer my prescription(s) to Park Ridge Pharmacy. I confirm that the information provided is accurate and complete.
40 Park Ave, Store #5, Park Ridge, NJ 07656 | (201) 554-2200 | parkridgerx@gmail.com
HIPAA Consent & Privacy Notice
NOTICE OF PRIVACY PRACTICES: Park Ridge Pharmacy is committed to protecting your health information. Your personal and health information will only be used to provide pharmacy services and will never be sold or shared without your written consent. You have the right to request access to your records at any time. For questions about your privacy rights, contact us at contact@parkridgepharmacy.com or call (201) 554-2200. Park Ridge Pharmacy — 40 Park Ave, Unit 5, Park Ridge, NJ 07656.
I have read and understand the HIPAA Notice of Privacy Practices and authorize Park Ridge Pharmacy to use my health information solely for the purpose of providing pharmacy services.
I confirm that all information provided in this form is accurate and complete to the best of my knowledge.
Should be Empty:

Transfer Your Prescription — Park Ridge Pharmacy

HIPAA Consent & Privacy Notice