College Intake Form
Keyes Drug offers free delivery of prescription and non-prescription medications to many schools and colleges in the Newton area. Fill out the form below to set up an account.
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Male
Female
Name of School
*
Student Phone Number
*
Please enter a valid phone number.
Student Email Address
*
example@example.com
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student's Insurance Information
Rx Bin #
*
Rx Group #
*
Rx PCN #
*
Cardholder ID #
*
Allergies
Any Allergies?
*
Yes
No
List your allergies
Medications
Do you take medications? (include over the counter medications and vitamins)
*
Yes
No
List your medications
Transfer Your Prescriptions to Keyes Drug
Do you have any active prescriptions at another pharmacy you would like us to transfer?
*
Yes
No
Name of Pharmacy to transfer from
Phone Number of Pharmacy to transfer from
Please enter a valid phone number.
List the medications that you wish to transfer to Keyes Drug - please indicate if you need any filled at this time
Billing Address
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
To expedite Rx processing and delivery, we need to have your credit card on file. After submitting this form, please call Keyes Drug at 617-244-2794 with your credit card information.
Please verify that you are human
*
Submit
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