Prescription Transfer Form - The Pharmacy at Bergheim

Patient Name*

Phone*

DOB*

Cell*

Cardholder ID#*

RX Bin*

Group #*

PCN*

Address*

Cardholder Name*

City*

State*

Zip*

Email address*

Allergies*

Current Pharmacy

Pharmacy Name*

Phone*

City*

State*

Zip*

Email address*

To Fill New Prescription

Patient Name*

Patient Name

DOB*

DOB

Prescription #*

Prescription #

Medication Name*

Medication Name

Prescribing Doctor*

Prescribing Doctor

Current Medications (including those that are over the counter)

Delivery

The Pharmacy at Bergheim pays for delivery to your home. Once The Pharmacy at Bergheim receives your prescription(s), you can expect to receive your packages within 1-2 business days.

Payment Options

The Pharmacy at Bergheim accepts all major credit cards, FSA/HSA cards, money orders and checks. Note: if paying by check, there is $30 charge for returned checks.

Name as it appears on card*

Card #*

Exp*

This field should be left blank