Transfer Prescription(s)
Which Cheek & Scott Location do you want to Transfer to:
*
Jasper
Lake City
Live Oak
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Contact Email
*
example@example.com
Contact Phone Number
*
-
Area Code
Phone Number
Is this a Cell Phone?
*
Yes
No
What Cellular Carrier is this Phone?
*
Examples: Verizon, AT&T, Sprint, T-Mobile, Cricket, etc...
Do you want to receive SMS Text Notifications on this number when your RXs are Ready?
*
Yes, please!
No, thank you.
Would you like to receive an automated voice call when your RX is ready?
*
Yes
No
Would you like to receive an Email when your RXs are ready?
*
Yes
No
Name of the Pharmacy you are Transferring FROM?
*
Example: Walgreens, CVS, Walmart, etc...
Phone number of the Pharmacy you are Transferring FROM?
RX Number(s):
One RX number per line
Comments:
Thank you!
Submit
Should be Empty: