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Prescription Transfer Form

Request to transfer prescriptions

Patient Information
Original Pharmacy's Information
Prescriptions to Transfer
Prescription 1
Prescription 2
Prescription 3
Prescription 4
Submission of this "Request to Transfer Prescriptions" form authorizes the University of Virginia, Department of Pharmacy to contact the above listed Pharmacy(s) for the sole purpose of requesting the transfer of the listed prescription(s) to the University Pharmacy and to proceed with the transfer upon receipt of approval.