Prescription Transfers

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Current Pharmacy Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current Pharmacy Phone

(###)

###

####

Prescription Bottle *

Would you like your prescription to be filled in an amber glass prescription bottle? Bottles are subject to a refundable deposit fee and do not have tamper resistant lids.

Yes - Fill my prescription in a glass bottle.

No - Fill my prescription in a plastic bottle.

N/A - My prescription does not come in a bottle.

Agreement to Transfer Prescription *

I agree to allow Seasons Pharmacy to contact my current pharmacy and any prescribers on my behalf. I agree to have my file and all prescriptions transferred to Seasons Pharmacy.

Yes, I agree to transfer prescription.

No, I do not agree to transfer prescription.