Keystone Professional Pharmacy Registration Form

Keystone Professional Pharmacy Student Registration Form. Please include copy of your Prescription and both sides of Prescription Insurance Cards.
  • Student Date of Birth
  • Please list any allergies to medication
  • Please list up to three existing medications your student currently takes. This is ONLY to assist in the insurance verification process - we do NOT use this for dispensing purposes.
  • Home PhoneCell Phone 
  • Name of School (if applicable)Location of School (State) 
  • Medication or School START DateMedication or School END Date 
  • Insured Name (Subscriber)DOB (Subscriber) 
  • Name of Prescription PlanPrescription Plan Phone 
  • Member/ID#RxBin#RxPCN#RxGroup#
  • Secondary InsuranceSecondary Insurance Phone
  • (2nd) Member/ID#(2nd) RxBin#(2nd) RxPCN#(2nd) RxGroup#
  • Current Pharmacy NamePhone Number 
  • Credit Card # (Visa/MC/Disc)Exp DateCVV CodeFull Name on Card
  • (HSA/FSA) Credit Card #(HSA/FSA) Exp Date(HSA/FSA) CVV Code(HSA/FSA) Full Name on Card
  • Please enter a number from 1 to 50.