• St. Paul's Student Form

    St. Paul's 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

  •  - -
    Pick a Date
  • Medications & Medical History

  • 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!
  •  - -
  • 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).
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Payment Information

  • prevnext( X )
    Prescription Copayments Product Image
    Prescription CopaymentsThe credit card provided will be charged monthly for your students prescription copayments. Payment amount will vary, if no prescriptions are prescribed nothing will be charged. Please ignore the $0.01/month listed below, it is purely to capture and securely store credit card information.
    $0.01 for each year
      

    Credit Card
    Billing Address
  • Additional Information

  • Should be Empty: