UT Student Intake Form for Tarrytown Pharmacy
Please fill out the following HIPAA-secure form in order to set up a patient profile at Tarrytown Pharmacy. The pharmacy will reach out with any questions. If you have any questions, please feel free to call the pharmacy at 512-478-6419 and ask to speak with the pharmacist. You can also send an email to ellie@tarrytownpharmacy.com. We look forward to taking care of your prescription and medication needs this year! Hook 'em!
Student (Patient) Information/Demographics
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Dorm/Apartment/Building Name
*
Dorm Room Number or Apartment Number (Hardin House- please include Main, Green, Red, Grant, etc)
*
Permanent Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Medication Allergies (if any)
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Prescription Insurance Information
Please provide the student's prescription insurance information below.
Prescription Insurance Provider (United, BCBS, Caremark, Cigna, Aetna, etc.)
RX Bin # (6 digit number)
PCN #
RX Group #
Member ID #
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Prescription Transfer
If you have current prescriptions you would like to transfer to our pharmacy, please answer the following questions. We will contact you once the prescriptions are transferred to get payment information and coordinate delivery.
Pharmacy Name (Where should we transfer the RX from?)
Pharmacy Phone Number
Names of all Prescriptions to Transfer
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Payment Information
For any prescription or OTC items to be delivered, we will need payment information to be put on file.
Name of who should we contact for payment info
*
Relation to student
Student
Parent
Other
Phone Number
*
Please enter a valid phone number.
Submit
Should be Empty: