IHS Pharmacy wants to make it easy for you to transfer a prescription from another pharmacy.
Simply fill out the form below and we’ll do the rest.

Patient name _____________________________

Date of birth _____________________________

Phone number _____________________________

Pharmacy prescription was last filled at________________________

Pharmacy telephone number ______________________________

Prescription refill number 1 ______________________________

Name of medication ______________________________

Prescription refill number 2 ______________________________

Name of medication ______________________________

Prescription refill number 3 ______________________________

Name of medication ______________________________

Prescription refill number 4 ______________________________

Name of medication ______________________________

Prescription refill number 5 ______________________________

Name of medication ______________________________

Prescription refill number 6 ______________________________

Name of medication ______________________________

Prescription refill number 7 ______________________________

Name of medication ______________________________

Prescription refill number 8 ______________________________

Name of medication ______________________________