Prescription Transfers

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone

(###)

###

####

Previous Pharmacy Phone number

(###)

###

####

Transfer Consent *

I am aware of the pharmaceutical services offered by Pharmacie Marc-André Couturier Inc and I agree to transfer my patient file including my active prescriptions, my insurance coverage, my pharmacotherapeutic history and the name and license number of the prescribers in my file. I understand that this transfer form gives Pharmacie Marc-Andre Couturier Inc consent to contact my pharmacy to complete the transfer. This decision has not been imposed on me and I remain free to change pharmacies at any time if I am no longer satisfied. In this case, this authorization would no longer be valid.

I consent

I don't consent