Transfer My Prescriptions - Premier Drugstore

Please fill out the form below and we will transfer your prescriptions and fill them at Premier Drugstore. Please include accurate contact info in case there are any issues.

Prescription Transfer Request

Patient Information

Prefix

First Name *

Middle Name

Last Name *

Gender *

Date of Birth *

Last 4 of SSN0 / 4

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Name of Pharmacy To Transfer From *

Pharmacy Phone *0 / 15

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer? *

Name of Drug *

Rx # *0 / 14

Do you have additional family members to have transferred? *

YesNo

Additional Insured Name

Date of Birth

Last 4 of SSN0 / 4

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional family members to have transferred? *

YesNo

Additional Insured Name

Date of Birth

Last 4 of SSN0 / 4

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional family members to have transferred? *

YesNo

Additional Insured Name

Date of Birth

Last 4 of SSN0 / 4

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional family members to have transferred? *

YesNo

Additional Insured Name

Date of Birth

Last 4 of SSN0 / 4

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Do you have additional meds to transfer for this family member? *

Name of Drug *

Rx # *0 / 14

Select

Insurance Information

We must either receive a picture of your card or you must enter the RxBIN, RxPCN, RxGrp, and Member ID from your card into form fields.

Member ID

Rx BIN0 / 6

RxPCN

RxGroup0 / 25

Additional Info0 / 500

Upload Picture of Insurance Card

Please make sure the image is clear. Please include front and back of card. Can upload multiple images.