Foothills Pharmacy Transfer Form

Transferring prescriptions to Foothills Pharmacy is easy! Fill out the form below or give us a call at 828-894-6112! Welcome to the Foothills Pharmacy family!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Pharmacy*
Current Pharmacy's Phone Number*
Please enter a valid phone number.
Please name the prescriptions you want to transfer to Foothills Pharmacy. (You can type "All" if you don't want to list each medication name)
Upload scan of insurance card

Cancelof
*If you chose not to upload your insurance information, please bring your insurance card during your first visit.
Would you like all your medications to be synchronized to be picked up at the same day each month?

YesNo
Should be Empty: