Transfer RX

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Submit your information in the form provided below. We are grateful for your enduring confidence in our pharmacist and drugstore staff.

You will enjoy exclusive discounts and privileges at Gaston Pharmacy when you transfer your prescription to us. We will be happy to receive your registration via the form below:

*First Name:

Middle Initial:

*Last Name:

*Date of Birth:

*Phone Number:

*Address:

*City:

State *

Select a Sate Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

*Zip/Postal Code:

*Pharmacy Name:

*Pharmacy Phone:

Prescriptions to be transferred

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if you would like to transfer all prescriptions, simply check the box below.

If you would like to selectively transfer your prescriptions, simply start typing to find your medication. List specific prescriptions to be transferred

MEDICATION NAME or Number

Medication Name or RX No.:

Medication Name or RX No.:

Medication Name or RX No.:

Medication Name or RX No.:

Medication Name or RX No.:

Medication Name or RX No.:

Medication Name or RX No.: