Changing Pharmacy Form | Bolton's Pharmacy

Patient First Name

Patient Last Name

Date of Birth

Month

Day

Year

Phone Number

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Current Pharmacy

Physicians that prescribe for you

I wish to inform the physicians listed above that I am switching my medications from my current default pharmacy to Bolton's Pharmacy, located at 128 West Main St in Watertown, NY. Please set them as my default pharmacy, and please send them all brand new prescriptions for me with whatever quantities and refill amounts the physician feels is appropriate.

Signature

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I would like Bolton's Pharmacy to enroll me in the free service:

28 Day Adherence Packaging

30 Day Medication Sync

None

I prefer to

Pickup my medications

Have my medications delivered