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Please fill in the form below to transfer your prescriptions to us.

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    First name*

    Birthdate:

    YOUR CONTACT INFORMATION

    All fields are required

    Address*
    City*
    State/Province*
    Zip/Postal Code*
    Country*

    Email*
    Phone*

    YOUR CURRENT PHARMACY

    Transfer from which pharmacy? *
    Phone number of pharmacy *

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