Transfer Your Prescription File to Dales Pharmacy Today!

It’s easy to transfer. Simply fill out this form and we’ll handle the rest.

Name*
First Last
Date of Birth*
Gender*
- Male
- Female
- Other
Home Address*
Street Address Address Line 2 City Province Postal Code
Home Phone
Cell Phone*
Email*
Insurance Information (Provider, Carrier, Version, Client ID):*
Name of Your Previous Pharmacy*
Address of Your Previous Pharmacy*
Which Dales Pharmacy Location would you like to transfer your prescriptions to?*
Primary Care Provider*
Medical Conditions*
Allergies*
Would you like to be set up on automatic prescription refill?*
- Yes
- No
Please speak to a pharmacy team member for more information
I authorize Dales Pharmacy to contact my current pharmacy and transfer my prescription and health profile on my behalf*
- Yes
- No
By entering your email, you are consenting to receive occasional correspondence from us.*
I agree.
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