LifeConnect Pharmacy

Transferring your prescriptions from another pharmacy or between Rexall locations has never been easier.

Transfer Prescriptions using Request Form

Complete the form below to transfer your prescriptions.

Patient Information

FIRST NAME

LAST NAME

BIRTH DATE

HOME PHONE

MOBILE PHONE

ADDRESS LINE 1

ADDRESS LINE 2

CITY / TOWN

STATE

ZIP CODE

Transferring Pharmacy Location

EXISTING PHARMACY

OTHER

PHARMACY PHONE NUMBER

Prescription(s) to be Transferred

Please provide us with drug name or prescription number for each of the prescriptions you would like to transfer to LifeConnect Pharmacy.

Yes, please transfer all of my prescriptions to LifeConnect

No, please only transfer the prescriptions listed below:

DRUG NAME

NUMBER

NOTES

DRUG NAME

NUMBER

NOTES

DRUG NAME

NUMBER

NOTES

DRUG NAME

NUMBER

NOTES

DRUG NAME

NUMBER

NOTES

Important Note

LifeConnect is committed to protecting the privacy of our customers' information. Any and all information provided on this form will be kept strictly confidential

By submitting this form you are giving consent for a LifeConnect representative to contact the transferring pharmacy indicated to complete your prescription transfer request.