Transfer RX FormPlease use the form below to transfer your prescription to Fort Lincoln Pharmacy.Patient DetailsName* First Name Last Name Date of Birth* MM slash DD slash YYYY Phone Number*Email Address Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pharmacy Name*Pharmacy Phone*Prescriptions To Be TransferredTransfer all my prescriptions* Yes NoIf you would like to transfer all prescriptions, simply check yes above. If you would like to selectively transfer your prescriptions, simply start typing to find your medication.List specific prescriptions to be transferredRX-1 Med NameMedication NameRX-1 #Prescription number from current pharmacyRX-2 Med NameMedication NameRX-2 #Prescription number from current pharmacyRX-3 Med NameMedication NameRX-3 #Prescription number from current pharmacyRX-4 Med NameMedication NameRX-4 #Prescription number from current pharmacyRX-5 Med NameMedication NameRX-5 #Prescription number from current pharmacyRX-6 Med NameMedication NameRX-6 #Prescription number from current pharmacyCaptchaPhoneThis field is for validation purposes and should be left unchanged.Δ
