Prescription Transfer Form

Prescription Transfer Form

Switching to Evara Pharmacy is simple. Complete the form below and our pharmacy team will contact your current pharmacy, transfer your eligible prescriptions, and let you know when everything is ready. Need help? Call us at 727-824-8181.
Tell Us About You
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
Your Current Pharmacy
Current Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Location (City or Address)
Which Prescriptions Would You Like to Transfer?
Which prescriptions would you like to transfer?
Specific medications
Instruction: If you choose to transfer only specific medications, list each medication below.
Confirmation
How Would You Like to Receive Your Medication?
Preferred medication receipt method
Delivery or shipping address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Insurance
Insurance Provider
Member ID
Group Number
Insurance Card

Cancelof
Anything Else?
Comments
Authorization
Should be Empty: