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Medication 2 Name and/or RX Number

Date of Birth *

Medication 1 Name and/or RX Number *

Choose: *

Pick Up

Delivery

Mail

Pharmacy Name: *

Message:

Pharmacy Phone Number *

Patient Name: *

Primary Insurance info: Bin# / PCN # / RX Group # / ID #

Street Address

City, State, Zip Code

If you have a current prescription with a different pharmacy, we can help you in transferring your records to Lake Ridge Pharmacy. We will contact your current pharmacy and promptly transfer your prescription(s). Also, please let us know if you have any prescription insurance coverage and any special needs. We look forward to serving you!

Start by filling out the Transfer Rx form below:

Some Brand name medications have equivalent Generic alternatives. You have the right to refuse such substitutions. Please check the box below if you wish to receive the Brand drug only.

Please fill my medications with Brand drug only as prescribed by the provider

Medication 3 Name and/or RX Number

Patient Name:

Request a Transfer

info@lakeridgepharmacy.com