Rogers Pharmacy...Today's Prescriptions, Yesteryear's Service!

Transfer your prescriptions to Rogers Pharmacy

We appreciate the opportunity to serve you and work daily to earn our customers' patronage!  Please complete the prescription transfer form below and we will reach out to you within 24 hours to confirm receipt of your transfer request and review your history and answer any questions you may have about the process.  Should you have more than 4 prescriptions to transfer, please complete the form as many times as needed.  If you have prescriptions for multiple family members please complete the form for each person and their associated prescriptions.

First Name 
Last Name 
Address 
Apt. # 
City/Town 
Zip Code 
State 
Phone Number 
Email 
Insurance Carrier 
Insurance Number 
Do You Have A Copay?
 
Copay 
Original Pharmacy Name 
Prescription Name #1 
Original Rx # 
Original Fill Date 
Refills Authorized 
RPH Name 
Prescription Name #2 
Original Rx # 
Original Fill Date 
Refills Authorized 
RPH Name 
Prescription Name #3 
Original Rx # 
Original Fill Date 
Refills Authorized 
RPH Name 
Prescription Name #4 
Original Rx # 
Original Fill Date 
Refills Authorized 
RPH Name 
Drug Allergies
 
If "Yes" to Allergies, Please Describe 
OTC & Other Merchandise Needed 
Store Pick up or Delivery