Transfer - East Point Pharmacy

Prescription Transfer Form

Fill out the form below. We’ll contact your current pharmacy and handle the transfer for you.

First Name *

Last Name *

Date of Birth *

Phone Number *

Address Line 1 *

Apt / Suite (Optional)

City *

State *

ZIP *

Pharmacy Name *

Pharmacy Phone *

Transfer all my prescriptions

If you check this, you don’t need to list medications below.

Medication Name

Rx Number (from current pharmacy)

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