Skip to content
Menu
Cart
Cart
Home
Services
COVID Testing
Pharmacy
Kim’s Connect
Medication Therapy Management
Immunizations
Travel Vaccines
Medication Synchronization
Smartphone App
About Us
Community Investment
Now Hiring
Refills
Patient Info
Patient Information Update
Transfer Rx
Contact
Close Menu
Close Cart
Transfer Rx
If you are human, leave this field blank.
Information for the pharmacy transferring from
Pharmacy Name
Pharmacy Phone Number
City
State
NC
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Patient Information
First Name
*
Last Name
*
Date of Birth
*
Phone Number
*
Email
List Medications (required) & Rx Numbers (optional)
Do you want to use child-resistant packaging?
Yes
No
Captcha
*
reCAPTCHA is required.
Submit
