Transfer a Prescription
Patient Details: Tell us about you so that we can verify who you are with your old pharmacy
Name
*
First Name
Last Name
Email Address*
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
New Pharmacy Location
Select which of our locations you'd like to use
Location*
*
Lecanto Pharmacy
Inverness Pharmacy
Previous Pharmacy Info
Tell us about your old pharmacy so we can transfer your medications
Pharmacy Name*
*
Pharmacy Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Prescriptions
Add the medication name and Rx number for all that you'd like to transfer
Please add individual RX information as follows: RX Number, Medication and Strength
*
Notes for Pharmacy (Optional)
Verify your insurance here or in the pharmacy when you get your medication
Questions or Comments
CAPTCHA
*
Submit Transfer
Should be Empty: