New Patient Waitlist

New Patient Waitlist

For individuals interested in becoming prescription patients at St. Paul Corner Drug
Patient Information
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Phone number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If/when we are able to take you on as a prescription patient, would you like be notified via call, text, and/or email?

CallTextEmail (please make sure you've included your email above!)
Your Household
Are there other individuals in your immediate household who you'd like to become prescription patients at St. Paul Corner Drug? If so, please enter their name, date of birth, their relationship to you, and any maintenance medications they take (i.e., prescriptions they regularly fill). When including the names of maintenance medications, use the exact name that's listed on their prescription bottle (e.g., don't write "Synthroid" if they actually take Levothyroxine, the generic version of this medication).
Your Medications
List the prescription medications you currently take below:*
Please use the name of the medication listed on your prescription; e.g., don't write "Synthroid" if you actually take Levothyroxine, the generic version of this medication
Your Insurance
If you currently have health insurance, please upload a photo of the front and back of your insurance card. If you have multiple insurance cards, use the one with "Rx" numbers on it (e.g., RxBIN, RxPCN).
Front of insurance card

Cancelof
Back of insurance card

Cancelof
Cost Plus
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
- Want to help support the vitality of our business and continued presence as a healthcare provider in our community
Click here for more information about our Cost Plus program.
After reading the above, would you be interested in joining our Cost Plus program?*

YesMaybeNo
Patient Attestation
By signing below, I attest that the information provided in this form is true and accurate to the best of my knowledge. I also understand that there is no guarantee if/when I will be able to become a prescription patient at St. Paul Corner Drug.
Signature of Patient (or Patient Representative)*

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Patient Representative (if signed by Patient Representative)

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

New Patient Waitlist

Patient Information

Your Household

Your Medications

Your Insurance

Cost Plus

Patient Attestation