Skip to content
Schedule an Appointment
Transfer a prescription
Patient Portal
About
About AvitaCare Atlanta
Our Services
Our Physicians
Leadership Team
Blog
Blog
Events
Contact
Contact Us
Referrals
Join Our Team
Schedule An Appointment
Transfer A Prescription
Patient Portal
Menu
About
About AvitaCare Atlanta
Our Services
Our Physicians
Leadership Team
Blog
Blog
Events
Contact
Contact Us
Referrals
Join Our Team
Schedule An Appointment
Transfer A Prescription
Patient Portal
About
Services
Our Providers
Discover
ATL Blog
Upcoming Events
Contact
Contact Us
Referrals
Join Our Team
X
Transfer A Prescription
Transfer Request - AvitaCare Atlanta - Formstack
ERROR:
JavaScript is not enabled. You must enable JavaScript in your browser to use this form
Please fill in a valid value for all required fields
Please ensure all values are in a proper format.
Are you sure you want to leave this form and resume later?
Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.
Save and Resume Later
Save and get link
You must upload one of the following file types for the selected field:
There was an error displaying the form. Please copy and paste the embed code again.
Apply Discount
You saved
with code
Request Transfer
Submitting
Validating
There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.
Please check the field:
Fields
Your Name
*
First Name
*
Last Name
*
Phone
*
Email
*
Birthdate
https://avita.formstack.com/forms/images/2/calendar.png
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
What is your current pharmacy?
*
What's their phone number?
*
What's your prescribing doctor's name?
*
Do you receive care at a healthcare center or community clinic? If so, what's the name?
Transfer All My Prescriptions
RX Numbers of Prescriptions to Transfer
Please type one on each line
Previous
←
Next
→
Enter your save and resume password
Cancel
Confirm