First Name *

Last Name *

Phone Number *

Date of birth *

Insurance Information (Optional)

Insurance Plan Name
Member ID
Group Number (Optional)

Email *

Current Pharmacy Name *

Address

Phone

City

State

Prescription Information

Transfer All Eligible Prescriptions to Inversa Rx Pharmacy

Transfer Specific Prescriptions

One Prescription

Medication Name
Strength
Rx Number

Two Prescriptions

Medication Name
Strength
Rx Number

Three Prescriptions

Medication Name
Strength
Rx Number

Four Prescriptions

Medication Name
Strength
Rx Number

By checking this box, I consent to receive text messages from Inversa Rx Pharmacy LLC regarding prescription services, refill reminders, transfer requests, order status updates, delivery notifications, appointment reminders, Inversa Rx Club membership services, and other pharmacy-related communications. Message frequency may vary. Message and data rates may apply. Text HELP for assistance or STOP to opt out at any time. Consent is not a condition of purchase.

Consent & Authorization

Authorization to Transfer Prescriptions

By checking this box, I authorize Inversa Rx Pharmacy LLC to contact my current pharmacy and request the transfer of my eligible prescription medications. I understand that controlled substances may not be transferable in accordance with federal and state laws. I certify that the information provided is accurate and authorize the release of information necessary to process this request.