Fill out the form below to Transfer your prescriptions:

Name:*

First

Last

Phone:*

Area Code

Phone Number

Date of Birth:*

day

month

year

E-mail:*

Home Address:*

Street AddressStreet Address Line 2CityProvincePostal Code

Name of the pharmacy you would like to transfer your file from:*

Pharmacy Phone Number::*

Area Code

Phone Number

Pharmacy Address (Not Required):

Street AddressStreet Address Line 2CityProvincePostal Code

How would you like to receive your medications?:*

Pickup

Delivery

Additional Instructions (Optional):

Word Verification: