St. Paul's Summer Program Student Form
Please fill out this form in its entirety to ensure our pharmacy has all information necessary to fill your child's medications.
Student Demographics
Name
*
Student's First Name
Student's Last Name
Date of Birth
*
-
Month
-
Day
Year
Student's DOB
Biological Gender
*
Male
Female
Medications & Medical History
Medication Allergies
*
If you have no allergies to medications please write N/A
Is there anything else the pharmacy should known about your student's medical history or a specific condition?
Parent or Guardian Contact Information
This individual will be contacted if we have any questions regarding student allergies, prescriptions, or conditions. As well as for financial issues or billing questions unless an alternative contact is provided for those matters. If another individual should be contact regarding financial issues or billing questions please make note in the additional comments box at the bottom of this form. Thank you!
Name
*
Parent or Guardian First Name
Parent or Guardian Last Name
Do you reside outside of the United States?
*
Please Select
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number. Please include area code.
International Phone Number
*
-
Country Code
-
Area Code
Phone Number
Prescription Insurance Information
Please fill out this information in its entirety, if your child does not have insurance, please select that you do not have prescription insurance at the beginning of this section to skip the rest of this section's questions. If you choose to take a picture or upload a picture of your child's insurance card, please make sure it is Prescription insurance (it will include a BIN, PCN, ID, & RX GRP).
Do you have active prescription insurance?
*
Please Select
Yes
No
Yes, I have two types of coverage!
Primary Insurance BIN Number
Primary Insurance PCN
Primary Insurance Group Number
Primary Insurance ID Number
Secondary Insurance BIN Number
Secondary Insurance PCN
Secondary Insurance Group Number
Secondary Insurance ID Number
Primary Prescription Insurance Card Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Prescription Insurance Card
Secondary Prescription Insurance Card Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Secondary Prescription Insurance Card
Payment Information
We will store this information on file for medication copayments and will charge prior to students receiving their medications.
Cardholders Name:
*
Cardholder's First Name
Cardholder's Last Name
Credit Card Number
*
Credit Card Expiration
*
Additional Information
Please provide any additional relevant information to the pharmacy below:
Submit
Should be Empty: