PRESCRIPTION TRANSFER REQUEST

Thank you for choosing to transfer your prescriptions to New Drug Loft in Manhattan, NY or VLS Pharmacy in Brooklyn, NY.

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What is your current pharmacy?*

Pharmacy Name*

Pharmacy Phone*

Pharmacy Location

Street Address City State ZIP Code

Transfer to New Drug Loft in Brooklyn or VLS Pharmacy in Manhattan:*

Rx Number(s)

Use the "+" sign to add as many as needed.

Patient's Name*

Patient's Phone Number*

Patient's Email Address*

Name

Group Number

Policy Number

Phone Number

No Insurance

Please check if patient does not have insurance.

Insurance Card Photos/Scans

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Max. file size: 16 MB.

You can upload the front and back photos or scans of your Insurance Card here.

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