Prescription Transfer Request

PATIENT INFORMATION AND CONSENT

First Name*

Last Name*

Phone Number*

Date of Birth*

Best time to call

YOUR CURRENT PHARMACY INFORMATION

Your Current Pharmacy*

Street Address

City*

State*

Phone Number

YOUR DOCTOR

Prescriber's Full Name

Phone Number

YOUR CURRENT MEDICATION(S)

RX Number

Medication Name*

Strength

Rx	Medication Name	Strength

I would like to receive offers and promotions from CostPill.

I authorize CostPill to contact the transferring pharmacy, prescriber, and myself.

CostPill provides thousands of commonly used medications at the most affordable prices.

* Cold shipping and brand medications will have additional costs to ensure secure receipt of delivery.

Useful Links

Stay up to date

Stay informed about exclusive deals, new product notifications, and company updates by joining us.