Transfer a Prescription
Please note that you may be contacted by a Transition Pharmacy representative to help facilitate and finalize the transfer of your prescription. Separately you will need to enroll in The HRT Club to begin receiving your prescriptions.
Patient Name
*
First Name
Last Name
Patient Phone Number
*
Please enter a valid phone number.
Patient Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Name of Current Pharmacy
*
Phone Number of Current Pharmacy
*
Please enter a valid phone number.
Address of Current Pharmacy
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name and Strength of Medication(s) to Transfer
*
Submit
Should be Empty: