First Name           Last Name 
Phone Number       eMail       

Delivery Options (Choose One)     Pick-up Soon  Pick-up Next-day  Please Deliver*

* If requesting delivery OR you are a new patient, please provide your correct address information below.  Note:  Delivery limited to Ada, Cascade, Forest Hills and Metro Grand Rapids areas at this time.

Street              
City                    State                Zip             

If you are a new patient, please provide your:

D.O.B.      
Medication Allergies (If any)

Pharmacy you are transferring prescription from:  CVS Meijer Rite Aid Walgreens Other
Other     
Originating pharmacy's phone number     

Enter Prescription Number(s) Below:  Note: Click HERE or on the image below for help locating your prescription information.

1)  3)  5)  7)  9)

2)    4)    6)    8)   10)

If you have more than ten (10) prescriptions to transfer, please submit your first ten, then revisit this page and submit your remaining prescriptions, making sure to complete all necessary information.