Transfer Prescriptions using Request Form

Complete the form to transfer your prescriptions.

Transfer Prescriptions Form

First Name*

Birth Date

Phone Number*

Address

Province

Last Name*

Your Email

Secondary Phone Number

City

Postal Code

Transferring Pharmacy Location

Existing Pharmacy

Other

Pharmacy Phone Number

Prescription(s) to be Transferred

Please provide us with the drug name or the prescription number for each of the prescriptions you would like to transfer to Pinetree Pharmacy. Yes, please transfer all of my prescriptions to Pinetree Pharmacy.No, I only want certain prescriptions to be transferred.

Important Note

Pinetree Pharmacy is committed to protecting the privacy of our customers' information. Any and all information provided on this form will be kept strictly confidential. By submitting this form, you are giving consent for a Pinetree Pharmacy representative to contact the transferring pharmacy indicated to complete your prescription transfer request. Prescription transfers occur digitally or via facsimile, and Pinetree Pharmacy may use third party service providers to facilitate a prompt transfer.

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