Request Prescription Transfer

We contact your current pharmacy and your prescriber, so you do not have to.

Prescription

One medication per request. To move several, send the form again for each, or call 832-886-4296 and read them out to a pharmacist.

Medication name

Dosage

Include the unit, for example 5 mg.

Transferring pharmacy

Pharmacy name

City

State

Pharmacy phone

Your prescriber

Prescriber full name

Prescriber phone

Your details and consent

We need these to confirm the prescription is yours before any pharmacy will release it.

First name

Last name

Phone

Date of birth

I authorise Zarina Pharmacy to contact the transferring pharmacy, my prescriber, and me about this request Yes No

Anything the pharmacist should know

Optional. Do not include card details.

Required fields are marked *. Do not send card details through this form.