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  • Transfer Request

    Please complete the following form to get the prescription transfer process started
  • Are you currently a patient with us?*
  • Date of Birth*
     - -
  • Is your mailing address different from your physical address?*
  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Gender*
  • Is this different from what insurance has on record?*
  • Which Gender are you registered on insurance with?*
  • What are your preferred pronouns?

  • It is important for our pharmacist to have the most up to date record of allergies, medical conditions, and medications being taken. 

  • Allergies*
  • Medical Conditions*
  • Do you have any medications that are/will be filled at another pharmacy (including specialty and mail-order medications)?*
  • Do you have prescription insurance?*
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  • Please provide as much of the following information as you can to help us provide an easy transition from your previous pharmacy.

    Please note that it can take up to 2 days to process transfers. If there is a medication that you need urgently, please call us at 425-788-2644. 

  • Is there an additional pharmacy we would need to contact for medication transfers?*
  • Should be Empty: