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Prescription Transfer

Date

Time

Intake RPh

Transferring Pharmacy Information

Pharmacy Name

Street Adress

Phone

City/State/Zip

Transferring RPh

Rx Number

Original Date

Last Fil Date

Refills Remaining

Pharmacy DEA (if CDS)

Prescriber Info

Name

Practice Name

Phone Number

Street Adress

Adress -2

Email

DVM DEA (if CDS)

Customer Profile Info

Patient Name

Wedgewood Cust #

Date of Birth

Species

Weight

Drug Allergies

Other Medications

Owner Name

Adress

Adress 2

Phone

Email

Prescription Info

Drug

Strength

Dosage Form

Quantity

Size

Sig

Refill

Drug

Strength

Dosage Form

Quantity

Size

Sig

Refill

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Location

470 E Fordham Rd, Bronx, NY 10458, Tel: 917-801-4700. Fax: 917-801-4701

1925 University Ave Bronx, NY, 10453 Tel: 347-750-5540. Fax: 347-750-5541

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