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Convert your Prescription

Enjoy free delivery of prescription and over-the-counter items Monday through Friday, with next-day, door to door service. It's easy to get started.

Simply use this form to transfer your existing prescriptions, or attach new prescriptions. Service is voluntary, and there are no contracts to sign. All transactions are confidential.

Personal Information

 My information is already on file

 There are my updates to my personal information

 New patient (complete all information below)

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone

Alternate Phone

Date of Birth

Email Address

 No known Allergies

 Yes, I have allergies (please list)

Current Pharmacy Name

Phone Number

 Transfer all of my prescriptions from another pharmacy

 Transfer only the prescriptions listed below

Prescription #

Drug Name

Prescription #

Drug Name

Prescription #

Drug Name

Prescription #

Drug Name

Prescription #

Drug Name

 My insurance information is already on file.

 I will fax a copy of my insurance card to 716.675.1314.

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