Doctor's Choice Pharmacy - Time Center

Available Forms

Refill A Current Prescription Transfer A Prescription

Transfer A Prescription

Full Name *

Sex *

Male

Female

Date of Birth *

Phone Number *

Email *

Address *

Pharmacy you are transferring from *

Please list the name of the pharmacy and location if multiple locations exist

Are you allergic to any medications? *

Yes

List Allergies

Please list all allergies

Please list all medications you are currently taking

Please list all medications you are currently taking, including over the counter

Do you have trouble reading labels? *

Yes

Do you have prescription insurance? *

Yes

Insurance Carrier

BIN #

PCN #

Group #

ID #

RX Number *

This is the RX number found on your last medication bottle

RX Number

Thank you for choosing to Doctor's Choice Pharmacy. Your order should be ready in an hour. A staff member will contact you when your medication is ready to be picked up.

* Required field