Transfer Prescription

Click "Next" Below

Personal Info

Are you a new patient or an existing patient? *

Patient First Name *

Patient Last Name *

Date of birth *

Phone *

Email *

Postal code *

I agree to terms & conditions provided by MDM Pharmacy. By providing my phone number, I agree to receive text messages from MDM Pharmacy.

- Please provide as much information about the pharmacy that has your prescription. -

Name of Pharmacy *

Address / Intersection of Pharmacy

Phone Number of Pharmacy *

Would you like to transfer all your prescriptions? *

Please transfer the following prescription(s) only: *

Would you like us to prepare your prescription(s) now? *

Please prepare the following prescription(s) now: *

I prefer *

Preferred Contact Method? *