St. Paul's School Intake Form
To help ensure that students receive their prescriptions in a timely manner, we kindly ask that you fill out our intake form. Please double-check that the student’s information, including any allergies, is current and accurate with the medical provider. We appreciate your cooperation!
Student Information
Please select the type of St. Paul's School student
New student
Returning student
Summer Program student
Name
*
Student's First Name
Student's Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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 the student's medical history or a specific condition?
Parent or Guardian Contact Information
We will contact this person if we have questions about a student's allergies, prescriptions, or medical conditions. For any financial issues or billing questions, we will also reach out to this person unless you provide a different contact for those matters. If you need us to contact someone else for financial issues or billing questions, please note that in the additional comments box at the bottom of this form. Thank you!
Parent/Guardian Contact
*
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 the student does not have insurance, please select 'No prescription insurance' at the beginning of this section to skip the remaining questions. If you choose to take a picture or upload a picture of your child's insurance card, please ensure it is a prescription insurance card (it will include a BIN, PCN, ID, and 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
*
Security Code
*
Credit Card Expiration
*
Additional Information
Please provide any additional information and/or billing contact details below.
Submit
Should be Empty: