The Apothecary at Wardenburg Health Center
University of Colorado Campus Box 119 Boulder, CO 80309
Phone: 303-492-8553 Fax: 303-492-4874
Prescription Transfer Request Form
- Please note that it generally takes 24-48 hours to transfer prescriptions. It may take up to 72 hours during the busy time.
- If there are no refills remaining, we will contact your prescriber. Please allow more time in processing your order.
Do you want to fill your medication after we transfer?
__ Yes, I want to fill now.
No, please keep my prescription on file
1. Patient Information
Last Name First Name Date of Birth (MM/DD/YYYY)
Student ID (if student)
Pharmacy Phone number
Best Phone Number
Local Address
2. Transferring Pharmacy Information
Pharmacy Name
Pharmacy Address City State
3. Prescriptions
We need either medication name or prescription number (if not both) to transfer prescription.
Medication Strength (optional) Rx number
Sig (Pharmacy Use Only)
Prescriber Prescriber phone number
4. Prescription Insurance Coverage
Student Gold Health Plan Other insurance plans No insurance coverage
Please return this completed form to apothecary@colorado.edu or fax to 303-492-4874
Pharmacy Use Only
Rx Date: ______________________________________ Prescriber DEA:
1
st
Fill: ________________________________________ Prescriber Address
Last Fill: ______________________________________
Original Refill: _______________________________
Refill Remaining: ____________________________
City
State
Zip Code
Zip code
Please fill all required fields, indicated as red boxes.
