Rx Transfer

Patient Information

All pages and forms used to transmit protected health information are
encrypted using Yahoo's SSL secure server with 128-bit encryption technology.

* First name:

* Last name:

* Date of Birth:

* Phone number:

* Address Line 1:

Address Line 2:

* City:

* State/Province:

* ZIP/Postal Code:

* Pharmacy Name:

* Pharmacy Phone:

Prescriptions to be transferred

Please check the following box if you would like to transfer all of
your prescriptions to Evergreen Pharmacy. Otherwise, please list
the prescription number(s) that you would like Evergreen
Pharmacy to fill.

Transfer all of my prescriptions

*Prescription # 1 / Medication Name

Prescription # 2 / Medication Name

Prescription # 3 / Medication Name

Prescription # 4 / Medication Name

Prescription # 5 / Medication Name

Requested Fill Date:

Additional Instructions or Requests:

Who is this prescription for?

* Required field

Prescription

Transfer

Super easy

Super convenient

Transfer your prescriptions to
Evergreen Pharmacy to receive

Greater cost savings
Quality pharmaceutical care
Fast service

We can easily transfer your existing prescriptions from
another pharmacy. Submit your prescription transfer
request and we will take care of the rest.

If you would prefer to give this information over the phone,
do not hesitate to call us or stop by with your prescription
bottles. We can get the information we need to fill your
prescriptions.

Prescription transfers will be processed during normal
business hours (9am to 6pm) and are usually ready within the
same day. If you send your transfer request after 6pm, we
will have it ready for you by close of the next business day.
We will contact you at the phone number you have provided,
if additional information is required. We will call you when
your prescription is available.

If you have any questions or concerns, please feel free to give
us a call.

Based on your previous selection, your
prescription transfer will be available at:

2365 Quimby Road Suite 150
San Jose, CA 95122
(408) 531-9961