TRANSFER PRESCRIPTIONS

First Name: *

Last Name: *

Phone Number: *

Date of Birth *

Email Address: *

Street Address *

Unit Number (If Applicable):

State / Province *

Postal / Zip Code *

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

Pharmacy Phone Number *

Street Address (Not Required)

Additional Instructions (Optional):

Terms of Service *

I agree with the terms of transferring my personal data electronically. And I have read the consent to use electronic communications.

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