Transfer your prescription

We are committed to protecting the privacy of customers’ information. All information provided on this form will be kept strictly confidential. By submitting this form you are giving consent for Ultima Pharmacy’s Pharmacist to contact the transferring pharmacy to complete your prescription transfer request.

Transferring your prescriptions from another pharmacy is fast and easy. Please provide the following information and we will take care of the rest.

Prescription Transfer/Refill

Submit your request online and we will notify you when your prescription is ready.

Name

First

Last

Phone

Select a service

Prescription Transfer

Prescription Refill

New Prescription

Submit your refill request and we will notify you when it is ready. Please enter your prescription or Rx number, which is usually found on your medication bottle.

Rx #1

Rx #2

Rx #3

Rx #4

Transferring your prescriptions to us is quick and easy. Please enter the name and phone number of the pharmacy you are requesting a transfer from, we will contact you shortly.

By law not all prescriptions can be transferred, speak with our Pharmacist for details.

Pharmacy's Name

Pharmacy's Phone Number

Upload a picture of your new prescription, we will notify you when it is ready for pick up! Please bring in the original prescription.

Maximum upload size: 67.11MB

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