Afton Pharmacy RX Transfer DemographicsName First Name Last Name Date of Birth MM slash DD slash YYYY GenderAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Consent OK to Text/EmailSSNDrug AllergiesPreferred LanguageConsent Please deliver all medications to address listed above.MedicationsConsent Transfer the medications listed below from my current pharmacy to Afton Pharmacy. (If multiple pharmacies, please specify.)1)2)3)4)5)6)7)8)9)Consent Please enroll me in the AutoRefill Program. Prescriptions will be filled regularly when due unless/until notified by patient or doctor.Debit or Credit Card NumberEXPCurrent Pharmacy NameCurrent Pharmacy PhoneConsent I authorize Afton Pharmacy to transfer all or selected prescriptions from my current pharmacy. I understand that I have the right to place my business with the pharmacy of my choice and that I may cancel this service and change pharmacies at any time.NameDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
