Transfer a Prescription

Name*

First Name

Last Name

Phone*

Birthdate*

MM/DD/YYY

Preferred Pharmacy Location*

Select which of our locations you'd like to use

Previous Pharmacy Name*

Tell us about your old pharmacy so we can transfer your medications

Previous Pharmacy Phone Number*

Tell us about your old pharmacy so we can transfer your medications

Prescriptions*

Transfer all of my medications Only transfer the medications listed below

Other:

Add the medication name and Rx number for all that you'd like to transfer

Are you an AHF Employee?

Yes No

Notes for Pharmacy (Optional)

Verify your insurance here or in the pharmacy when you get your medication