The Rock Hill Pharmacy is always looking to add new members to our
family.   Simply fill out the form below and we will contact your old pharmacy
to transfer your medications over to our pharmacy.
*Please note - NY Law does not allow the transfer of Control Substance Prescriptons or
prescriptions paid for by the NY Medicaid Program.
Patient Name:
(Required)

Patient DOB:
(Required)

Patient Phone Number:
(Required)

Patient Address:

Patient Allergies:

Old Pharmacy Name:
(Required)

Old Pharmacy
Phone Number:
(Required)
Medications to be Transfered
Old Pharmacy       Prescription Number    Medication Name
Prescription #1

Prescription #2

Prescription #3

Prescription #4

Prescription #5

Prescription #6

Special Instructions:
(Automatic Refills)
Prescription Transfers