RX Prescription

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When you transfer your prescription to our pharmacy, you receive a gift card as our way of showing our appreciation. You get a 10-dollar gift card when you transfer 2 maintenance medications and a 25-dollar gift card when you transfer 4 maintenance medications.

*Please note that Medicaid, Medicare, and any other federal and state government or other publicly funded program prescriptions are not eligible. A maximum of 25 dollars per customer will be given. These gift cards are not valid on prescriptions for controlled substances where prohibited by law.

To begin the process of transferring your prescription, please fill out the form below with the needed information. Thank you for making Burleson Pharmacy your pharmacy of choice!

Fill Prescription form

FIRST NAME *

LAST NAME *

DATE OF BIRTH *

PHONE NUMBER *

ADDRESS

CITY

STATE

ZIP/POSTAL CODE

PHARMACY NAME

PHARMACY PHONE

PRESCRIPTION TO BE TRANSFERRED

If you would like to transfer all prescription, simply check the box below.

Transfer all my prescriptions

If you would like to selectively transfer your prescription, use the option below.

LIST SPECIFIC PRESCRIPTION TO BE TRANSFERRED

MEDICATION NAME

RX1 MED NAME

RX2 MED NAME

RX3 MED NAME

RX4 MED NAME

RX5 MED NAME

PRESCRIPTION NUMBER FROM CURRENT PHARMACY

RX1 NUMBER

RX2 NUMBER

RX3 NUMBER

RX4 NUMBER

RX5 NUMBER

Submit

344 SW Wilshire Blvd, Suite P Burleson, TX 76028

Phone: 817-720-5555

Fax: 817-720-5554

burlesonpharmacy@gmail.com

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