Prescription Transfer Request

New Patient Intake Form

For new patients that haven’t filled a prescription or received a vaccine at St. Paul Corner Drug
New Patient Policy
As of May 30th, 2024, we are once again accepting new prescription patients. As time goes on, we’ll continue to check in with our bandwidth to ensure that our staff remains able to provide the safe, efficient pharmacy care we’re known for.

If you haven’t filled prescriptions at our pharmacy before (including individuals who have only been vaccinated by us) and would like to begin doing so, please complete this form in full.
Name of SPCD staff member (if applicable)
Next Steps
If you haven't already spoken with an SPCD staff member before completing this form, after doing so please give us a call at (651) 698-8859 so that we can further assist you! We'll need to confirm some information, including whether you'd like any prescriptions filled immediately.
Patient Information
Name (as insurance has on file)*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Sex (as insurance has on file)*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary phone number*
Please enter a valid phone number.
What type of phone is this?*

CellHomeWork
Email
example@example.com
Allergies
If you have allergies to any drugs or other substances, please list them below. If you're unsure about the severity of your allergy, select "unsure" and we'll discuss it with you in person.

An "allergic reaction" includes any reaction that occured within 4 hours of exposure and caused hives, swelling, or repiratory distress (including wheezing), as well as a severe allergic reaction (e.g., anaphylaxis) that required treatment with epinephrine or EpiPen®, or that caused you to go to the hospital.
I have the following allergies to drugs or other substances:
OR check this box:

I have no known allergies to drugs or other substances
Insurance
If you currently have health insurance, please upload photos of the front and back of your insurance or pharmacy benefit (if this is separate from your medical) card or enter the following numbers in the fields provided. If you don't currently have health insurance or don't want to bill your prescriptions to insurance, check the box provided.

Be aware that insurance cards without any "Rx" numbers on them are for the billing of medical services ONLY and the numbers they include will NOT be able to be used at our pharmacy for the billing of your prescriptions and vaccinations. Additionally, not all insurance plans use an RxBIN, RxPCN, and RxGRP in the billing of prescription claims (which includes the billing of vaccinations provided by pharmacies), so if you can't find one of these numbers on your card, don't worry.

If you can't find your prescription coverage card or were never given one, we can try searching for your insurance. If we're unable to successfully search for your insurance information, you'll be required to determine this information by calling your insurance company.
Front of insurance card

Cancelof
Back of insurance card

Cancelof
Name of plan (e.g., UCare)
ID
RxBIN
RxPCN
RxGRP
OR check this box:

I don't currently have health insurance or don't want to bill my prescriptions to insurance
Medicare

If you're a Medicare patient, please you can upload a photo of the front of your Medicare card or enter the following information in the fields provided. If you don't currently have access to your card, please provide this information the next time you interact with us.
Front of Medicare card

Cancelof
Name (as appears on Medicare card)
Medicare number (####-###-####)
NOTE: Your Medicare number is no longer your Social Security Number (SSN). If you still have a Medicare card that lists your SSN, leave this card in a safe space at home and contact Medicare ASAP to request that they send you a new card!
Cost Plus

Our self-pay program
Did you know that we have a self-pay program at our pharmacy for patients interested in paying out of pocket for some or all of their prescriptions? This program is a great fit for patients who:
- Take cheap generic medications
- Are tired of navigating the difficulties of working with insurance (e.g., prior authorizations)
- Take medications that aren't covered by their insurance plan (e.g., are given only a certain number of "transition fills" before being forced to fill at a different pharmacy)
- Are forced by their insurance to move to a different retail pharmacy or mail order pharmacy
- Have a high-deductible health insurance plan and are unlikely to meet their deductible
- Have health insurance that is not accepted at St. Paul Corner Drug
- Don't have health insurance with prescription drug coverage
Click here for more information about our Cost Plus program.
After reading the above, would you be interested in joining our Cost Plus program?*

Yes (if so, mention this to a Technician or Pharmacist when you give us a call after completing this form)MaybeNo
Prescription Cap Type Preference
Do you prefer that we use safety or non-safety caps on your prescription bottles?*

Safety (child-proof)Non-safety (easy-open)
Notification Preferences
We can notify you when your prescriptions are ready! Notifications can be received via our app, RxLocal (HIPAA-compliant), traditional SMS text (not HIPAA-compliant), and/or email (not HIPAA-compliant). For reasons listed here, we prefer patients use RxLocal if that works for them.

Please note that for adult patients (18+ years old) we CANNOT send notifications to anyone but the patient directly without the patient’s consent. So, if you are completing this form on behalf of an adult patient, please skip this section. If you'd be interested in receiving notifications on behalf of an adult patient (e.g., a grown child who's currently attending school out of state), have that patient complete our Patient Authorization for Release of Medical Information (ROI) form, which is available on our Forms & Documents web page. We also have hard copies available at our store.
Which types of notification do you prefer? (check all that apply)

RxLocal (preferred; to enroll, visit stpaulcornerdrug.com/refill)TextEmail
Alternate phone number
Please enter a valid phone number if you'd like an alternate phone number listed on your profile
What type of phone is this?

CellHomeWork
Receiving Your Filled Prescriptions
If you'd like, we can set the default in your profile to pickup, delivery, or mailing of your filled prescriptions. Note that you can change this default preference at any time as well as request a non-default option as needed (e.g., if you usually pick up your prescriptions but would prefer to have your next refill mailed to you).
What is your preferred method for receiving your filled prescriptions?*

PickupDelivery (available Monday - Friday for a fee based on zip code)Mail (only allowed for Minnesota addresses per federal regulations)
Name & Gender Recognition
Per our Name & Gender Recognition Policy for Transgender, Transitioning & Gender Non-Conforming Patients, the name below will be included in parentheses alongside the first name your insurance has on your prescriptions (e.g., "GUTIERREZ, AMAYA (ZAY)"). You can also select your preferred pronouns.
Preferred first name
Pronouns (check all that apply)

She / HerHe / HimThey / ThemOther
Pronouns

He / HimShe / HerThey / ThemOther
Prescription Transfer Request
If you are currently filling prescriptions at another pharmacy and would like us to request those prescriptions be transferred to us, please provide that pharmacy's information below.

Because the transfer process can take multiple business days, if you currently have less than a one-week supply left of any medication, we recommend you get a refill at your current pharmacy before having us transfer that prescription.

Please note that we continue to have difficulty transferring prescriptions from chain pharmacies due to their staff shortages and other service issues. For this reason, we will only contact a chain or mail order pharmacy ONCE to request a prescription transfer; if that attempt fails, it will be your responsibility to request that your care provider send us a new prescription order(s) directly. We are not currently experiencing difficulty transferring prescriptions from independent pharmacies and are happy to do so.
Pharmacy prescription(s) is/are being transferred from:
Name
Phone number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescription(s) to be transferred:
Prescriber Information

Occasionally, a prescription that we attempt to transfer is out of refills or expired and therefore CANNOT be transferred. This is also true for prescriptions for controlled medications (e.g., opioids, stimulants). In these cases, we will contact the last care provider by whom it was prescribed to get a new prescription order. Please include their contact information below.
Additional Comments
Is there anything else you'd like us to know about you?
Patient Attestation
By signing below, I attest that the information provided in this form is true and accurate to the best of my knowledge.
Signature of Patient (or Patient Representative)*

Powered by Jotform SignClear
Patient Representative (if signed by Patient Representative)

First NameLast Name
Relationship to Patient (if signed by Patient Representative)
Should be Empty: