Transfer Rx Multi-Step Form

Transfer Your Prescriptions

To our stress-free pharmacy. Seriously!

Patient Information

Pharmacy / Rx Info

Finally

Patient Information

Step 1/3

First Name *

Last Name *

Email *

Phone *

Street Address *

City *

State *

Zip Code *

Do You Have Prescription Insurance?

Yes

Okay, we will use our discount card to save you a lot of money! If you are getting a brand-name medication, get the manufacturer's co-pay card from the website if available.

Can You Upload A Copy?

Yes

Do You Have The Rx Card With You?

Yes

We will try to pull the information from your Rx insurance company database. Depends on if your insurance company is integrated with our system. But bring the card or information to the pharmacy when picking up your prescription.

Please Upload Rx Insurance

(Upload Rx card with Rx bin, Rx group) Max file size is 10MB.

Upload File

Please upload insurance info before submitting.

Let's get the Rx Bin, Rx Group, Rx ID # from the card

Rx Bin #

Rx PCN

Rx Group #

Rx ID#

Gender *

Date Of Birth *

Drug Allergies? *

Yes

Please List Drug Allergy

Let's get the pharmacy information ...Tap Next to continue.

Pharmacy Name *

Name Of Pharmacy

Pharmacy Phone#

Prescription Information

Should We Transfer All Your Prescriptions?

Yes

Please know that certain rules and regulations apply. For example, Prescriptions without refills or expired (greater than one year) will not be transferred. Call the doctor's office to send new prescriptions. Prescriptions you are no longer taking may be transferred. Please specify what not to transfer in the comments section. The transfer of controlled substances has special rules and regulations. We recommend you have the doctor's office send new prescriptions for controlled substances to Red Apple Pharmacy.

We will need information from the prescription label:

Rx Number

Drug Name:

Doctor's Name:

Doctor's Phone #

Any Refills Remaining?

Yes

Please call the doctor's office to send us a new prescription. The original pharmacy will not transfer prescriptions without refills.

Any More Prescriptions To Transfer?

Yes

Any More Prescriptions To Transfer?

Yes

Rx Number

Drug Name

Same Doctor?

Yes

Doctor's Name

Doctor's Phone#

Any Refills Remaining?

Yes

Please call the doctor's office to send us a new prescription. The original pharmacy will not transfer prescriptions without refills.

Any More Prescriptions To Transfer?

Yes

Any More Prescriptions To Transfer?

Yes

Rx Number

Drug Name

Same Doctor?

Yes

Doctor's Name?

Doctor's Phone#

Any Refills Remaining?

Yes

Please call the doctor's office to send us a new prescription. The original pharmacy will not transfer prescriptions without refills.

Any More Prescriptions To Transfer?

Yes

Any More Prescriptions To Transfer?

Yes

Please list them below:

Drug Name(s)

Estimated Pickup time

Like To Transfer Prescriptions For Other Family Members?

Yes

Not At This Time

Please Tell Us The Names And DOB:

First Name

Last Name

Date Of Birth

Transfer All Prescriptions?

Yes

Please List Drugs To Transfer

Any One Else?

Yes

Any One Else?

Yes

First Name

Last Name

Date Of Birth

Transfer All Prescriptions?

Yes

Please List Drugs

Any One Else?

Yes

Any One Else?

Yes

First Name

Last Name

Date Of Birth

Transfer All Prescriptions?

Yes

Please List Drugs

Anything Else We Need To Know?

I hereby authorize Red Apple Pharmacy to transfer my prescriptions from the pharmacy listed above following state and federal rules and regulations. *

Okay, Submit this form so our pharmacist will start the process of transferring your prescriptions.

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