Rx Transfer

PHONE: 208-922-4400 FAX: 208-922-4499

PRESCRIPTION TRANSFER FORM

Name of Pharmacy Where Prescription was Last Filled

Phone Number of Above Named Pharmacy

PRESCRIPTION NUMBER

NAME

NOTE: Not all prescriptions are transferable. Please contact us at 208-922-4400 if you have any questions.

Phone Number Where You Can Be Contacted

DATE OF BIRTH
MMDDYY

Rest assured that Custom Rx Pharmacy takes all necessary steps to ensure that your private information remains private including a High Level SSL Security Certifcate.

      * An SSL Certificate enables encryption of sensitive
         informatiuon during online transactions.

      * Each SSL contains unique, authenticated informsation about
         the certificate owner.

      * Every SSL Certificate is issued by a Certificate Authority that
        verifes the identity of the certificate owner.