Carefully complete the
Transfer form
and click on the SEND button.
If you require assistance, please call directly at:
1.877.525.6554
Transfer Form
Name
Mailing address
Home address
Telephone number (Office)
Telephone number (Home)
E-Mail address
Pharmacy name
Pharmacy phone number
Prescription number
Medication name
Prescribing doctor's name
If you have more than one prescription, select your browser's back button after submitting, change the prescription information and then resubmit.