Transfer RX

Transfer your prescription to George’s Pharmacy by filling out the form below.

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pharmacy Name*
Pharmacy Phone*
Prescriptions to be transferred
If you would like to transfer all your prescriptions, please check the box below.
- Transfer all my prescriptions
List up to 20 prescriptions that you want to transfer. If you checked the above box to transfer everything, you don't need to fill this out.
Medication Name
Prescription Number from Current Pharmacy
Time of Day
Morning
Noon
Evening
Bedtime
How Did You Hear About Us?
Name of Agency/Case Manager
Click to Verify

Prescriptions to be transferred