Transfer RX

If you are not a member of Apollo Pharmacy and would like to use our service you can transfer your account to us. If your current pharmacy is part of the common Rx network, just fill the below given form and get your account transferred to us. Your information will be secure during account transfer.

Send us a message through the form below:

* = Required Information

Patient Details

Please enter your details below. All fields marked with an asterisk are required.

First Name: *

Middle Initial:

Last Name: *

Date of Birth:

Address

Phone Number: *

Pharmacy Name:

Pharmacy Phone:

INSURANCE INFORMATION (OPTIONAL)

Cardholder Last Name:

Cardholder First Name:

Cardholder ID:

BIN:

PCN:

Prescriptions to be transferred

If you would like to transfer all prescriptions, simply check the box below.

Transfer all my prescriptions

If you would like to selectively transfer your prescriptions, simply start typing to find your medication. List specific prescriptions to be transferred

MEDICATION NAME

PRESCRIPTION NUMBER FROM CURRENT PHARMACY

Rx1 Med Name:

Rx 1 #:

Rx2 Med Name:

Rx 2 #:

Rx3 Med Name:

Rx 3 #:

Rx4 Med Name:

Rx 4 #:

Rx5 Med Name:

Rx 5 #:

Rx6 Med Name:

Rx 6 #:

Rx7 Med Name:

Rx 7 #:

Rx8 Med Name:

Rx 8 #:

Rx9 Med Name:

Rx 9 #:

Rx10 Med Name:

Rx 10 #:

* = Required Information

Please enter any two digits with no spaces (Example: 12) *
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Transfer RX

Send us a message through the form below:

* = Required Information

Patient Details

INSURANCE INFORMATION (OPTIONAL)

Prescriptions to be transferred

* = Required Information

.

Contact Information

Days & Hours of Operation

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