Prescription Transfer Request Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Previous Pharmacy
If more than one location, please also provide the city and street.
Previous Pharmacy Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type a question
Transfer all of my prescriptions
Just transfer the RX(s) that I enter below
Type prescription name or number that you would like us to transfer below.
Which medications do you need filled today? (You may say "None" if you would like us to hold the prescription(s) until requested.)
Additional notes for the pharmacy staff. (Ex: Discount card on file at Kroger for Mounjaro)
Are you a new patient? If yes, please fill out the additional New Patient Form at www.pharmacylakecharles.com
Yes
No
Signature
Submit
Submit
Should be Empty: