Bayless Integrated Healthcare

First Name*

Last Name*

Date of Birth*

Gender*

Email Address

Phone Number*

Mobile or Home

Pharmacy and Prescription Information

Pharmacy Name

Pharmacy Cross Streets or Address*

Prescription Transfer

Prescription Names

Upload images of RX labels, RX lists, discount cards and/or insurance.

Upload Files

Drop files here or

Consent*

I understand that by submitting this form I consent to transfer my prescriptions to SpotRx pharmacy*

Refill

*Fields required.
By submitting this form, I acknowledge that I have read and accept the SpotRx Terms and Privacy and HIPAA FORMS Service Privacy Statement.

Locations & Hours