Cane Creek Pharmacy - Transfer Prescriptions

TESTING PAGE - DO NOT USE FOR PRESCRIPTIONS

This page is being tested for future use.
If you need assistance please contact our office at (828) 628-3675.

Name:

Address:

City, State, Zip:

, ,

Phone:

Email Address:

Pickup or delivery?

Pickup
Delivery

Please enter all of the digits of your old prescriptions

	Refill? Yes No
	Refill? Yes No
	Refill? Yes No
	Refill? Yes No
	Refill? Yes No
	Refill? Yes No
	Refill? Yes No
	Refill? Yes No

Prior Pharmacy Information

Pharmacy Name:

Address:

City, State, Zip:

, ,

Phone:

Additional Notes:

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