Transfer My Prescription

Please complete the form and we will get your prescription transferred to S&S as quickly as possible. 

1. Patient first name
2. Patient last name
3. Birthdate (MM/DD/YYYY)
4. Patient phone number
5. Patient email address
6. Patient address (please include street, city, state and zip code)
7. Current pharmacy
8. Current pharmacy phone number (if you have it)
9. Current physician
10. Current physician phone number
11. Not Used