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Request to transfer prescriptions

* Transfer location:



 
Patient Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* Country, State/Province:
* Postal Code:
* Phone Number: ext.
Fax Number: ext.
* UVA Student or MRN No.:
* Birth Date (MM/DD/YYYY):

Original Pharmacy's Information
* Pharmacy Name:
Address 1:
Address 2:
City:
Country, State/Province:
Postal Code:
* Phone Number: ext.
Fax Number: ext.

Prescriptions to Transfer
Prescription 1:
* Number: * Drug Name:
* Strength: * Physician:
Prescription 2:
Number: Drug Name:
Strength: Physician:
Prescription 3:
Number: Drug Name:
Strength: Physician:
Prescription 4:
Number: Drug Name:
Strength: Physician:

Submittal of this "Request to Transfer Prescriptions" form authorizes the University of Virginia, Department of Pharmacy to contact the above listed Pharmacy(s) for the sole purpose of requesting the transfer of the listed prescription(s) to the University Pharmacy and to proceed with the transfer upon receipt of approval.

* Click here to accept terms.