Rx Transfer Intake
Share the details needed to start a pharmacy-to-pharmacy prescription transfer.
Patient full name
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current pharmacy name
*
Current pharmacy phone
Please enter a valid phone number.
Format: (000) 000-0000.
Medications to transfer
Transfer all of my prescriptions from this pharmacy
Transfer all of my prescriptions from this pharmacy
Pickup or delivery
*
Please Select
In-store pickup
Local delivery (eligibility confirmed)
Not sure
Best time to call
I authorize TFC Pharmacy to contact my current pharmacy and, if needed, my prescriber to transfer the prescription(s) listed above. I understand a pharmacist may call me to confirm details, that some prescriptions (e.g. certain controlled substances) may not be transferable, and that submitting this form does not guarantee a transfer until confirmed by a pharmacist.
*
I authorize TFC Pharmacy to contact my current pharmacy and, if needed, my prescriber to transfer the prescription(s) listed above. I understand a pharmacist may call me to confirm details, that some prescriptions (e.g. certain controlled substances) may not be transferable, and that submitting this form does not guarantee a transfer until confirmed by a pharmacist.
Submit
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