Transfer My Prescriptions
Use the following HIPAA Secure Form to transfer your prescriptions from another pharmacy to Integrity Compounding Pharmacy.
Name
First Name
Last Name
Date of Birth (mm-dd-yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Prescription # 1
RX #
Prescribing Physician Name
Name of Medication
Strength
Quantity
Does this prescription have refills?
Yes
No
Unknown
Prescription # 2
RX #
Prescribing Physician Name
Name of Medication
Strength
Quantity
Does this prescription have refills?
Yes
No
Unknown
Prescription # 3
RX #
Prescribing Physician Name
Name of Medication
Strength
Quantity
Does this prescription have refills?
Yes
No
Unknown
What is the name of your current pharmacy?
Pharmacy Phone #
Pharmacy Address (Optional)
Submit
Should be Empty: