TRANSFER FORM

Transfer a Prescription

Patient Details

Tell us about you so that we can verify who you are with your old pharmacy

Name *

First

Last

Phone *

Birthday

New Pharmacy Location

Select which of our locations you'd like to use

Pharmacy Location

Previous Pharmacy Info

Tell us about your old pharmacy so we can transfer your medications

Pharmacy Name *

Pharmacy Number *

Prescriptions

Add the medication name and Rx number for all that you'd like to transfer

Checkboxes

Transfer all of my medications
OR, List the Medications you want to transfer

Medication & Rx Number

First

Last

Medication & Rx Number

First

Last

Medication & Rx Number

First

Last

Notes for Pharmacy(Optional)

Verify your insurance here or in the pharmacy when you get your medication

Message

Checkboxes

I agree to the Terms and Conditions and Privacy Policy

If you have any questions,

please feel free to call and speak to one of our pharmacists

ABOUT HEALTH HERO

Health Hero Pharmacists specialize in understanding a patient’s needs. We play a key role in helping patients feel better and get well as soon as possible. When a pharmacist is part of a patient’s healthcare team, it goes to benefit the patient in the long run.