Transfer Request
Do you want to transfer your prescription to Farmer's MedShoppe? It's simple! Just complete the form below and we'll take care of the rest.
Please complete the transfer form and we will be in contact you
Name*
Required field!
Email*
Required field!
Phone*
Required field!
Email*
Required field!
Birth Date*
Required field!
Address
Required field!
City
Required field!
State
Required field!
Zip / Postal Code
Required field!
Health Insurance Number
Required field!
Transfer From
Required field!
Pharmacy Name*
Required field!
Pharmacy Number*
Required field!
Prescriptions to be transferred
If you choose to transfer only select prescriptions, please provide the drug name or prescription number for each one you'd like to transfer.
Required field!
List Prescription Number or Drug Name
Required field!
Required field!