Transfer Prescription

* Indicates required field

Name (Nombre) *

First

Last

Phone Number (Numero de telefono) *

Date of Birth (Fecha de naciemento) (00/00/0000) *

Current Pharmacy (Farmacia regular) *

Current Pharmacy Phone number (Telefono de Farmacia regular) *

Transfer all prescriptions? (Transferir toda la prescripción?) *

If no, please list the medication name(s) that you'd like to transfer *

Submit

* We do not dispense promethazine w/ codeine*