Some restrictions apply to the transfer of prescriptions for narcotics and controlled drugs.
For more information please contact us at 1-877-525-6554 or firstname.lastname@example.org
First Name (required)
Home phone (required)
Other phone (bureau)
Home address (required)
Code postal (required)
---Ship to my homeShip to the address below
Shipping postal code
Pharmacy name (required)
Pharmacy phone (required)
Prescribing Doctor's Name (required)
How many prescriptions do you wish to transfer?
Prescription Number (separate multiple with commas ",")
Medication Name (separate multiple with commas ",")