Rx Refills

Prescription Transfer Form

Please complete the following HIPPA-secure form to transfer your prescription(s) to our pharmacy. We'll use this information to contact your current pharmacy and transfer your prescriptions. We appreciate your business and look forward to serving you and your loved ones.
Patient Information
Patient Name*

First NameLast Name
Patient Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Transferring Pharmacy

Please provide us with some information about the pharmacy where you are currently filled.
Current Pharmacy Name*
Current Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Zip Code
Zip Code
Prescription Information

*Note: Your existing controlled medication prescription is not subject for a transfer. Please contact your doctors office to send a new prescription.
Would you like to transfer all of your prescriptions to TFC Pharmacy?*

Yes, transfer all of my prescriptions to TFC PharmacyNo, only transfer the prescriptions listed below:

Medication Name or Rx Number*

Medication Allergies (list below)*
Are you taking any other medications? (OTC, prescription or supplements?)*
Insurance Information

*NOTE: YOUR PRESCRIPTION INSURANCE IS LIKELY NOT THE SAME AS YOUR MEDICAL INSURANCE*
Insurance Agency Name (Type N/A for Non-Insured applicants)
Cardholder Last Name
Cardholder First Name
Insurance ID #
BIN #
PCN #
Group No. #
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Receive Options*
Some restrictions may apply.
Upload a photo of your prescription here (Optional)

Cancelof
Thank you for completing the transfer prescription form. You may electronically submit the order to TFC PHarmacy & Compounding by clicking "Submit" below.

A Patient Services Representative will contact you within 24 hours.
Please verify that you are human*
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Prescription Transfer Form