DISCLAIMER: By law, NARCOTIC AND RESTRICTED MEDICATIONS CANNOT BE TRANSFERRED, BENZODIAZPINES (ex: diazepam, lorazepam, clonazepam, etc.) CAN ONLY BE TRANSFERRED ONCE. Pharmacies are not connected. We use this information to call other pharmacies to obtain the transfer. Thank you for your understanding.

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Date of Birth (DD/MM/YEAR) (required):

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Tel Number Of Pharmacy To Transfer From (required):

Type Prescription Numbers Or Names Of Medications You Would Like Transferred (required):

Please Indicate Prescriptions You Would Like Filled Now, And Which Ones To Hold For Later (required):


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