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 Name* First Middle Last Student DOB*Student Date of BirthMale / Female*MaleFemaleMedication AllergiesPlease list any allergies to medicationExisting Medication (for insurance verification)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.Parent/Legal Guardian Full Name*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phones*Home PhoneCell Phone School (if applicable)Name of School (if applicable)Location of School (State) Start Dates*Medication or School START DateMedication or School END Date Email of Parent* Insured*Insured Name (Subscriber)DOB (Subscriber) Prescription PlanName of Prescription PlanPrescription Plan Phone Prescription Member Info*Member/ID#RxBin#RxPCN#RxGroup#Secondary Insurance (If Applicable)Secondary InsuranceSecondary Insurance PhoneSecondary Insurance Member (if applicable)*(2nd) Member/ID#(2nd) RxBin#(2nd) RxPCN#(2nd) RxGroup#PharmacyCurrent Pharmacy NamePhone Number Credit Card (Visa/MC/Disc)Credit Card # (Visa/MC/Disc)Exp DateCVV CodeFull Name on CardBilling Address (if different than home address) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HSA/FSA Credit Card (if applicable)(HSA/FSA) Credit Card #(HSA/FSA) Exp Date(HSA/FSA) CVV Code(HSA/FSA) Full Name on CardPlease Check the Following Items:* I am aware that if no specific time is written on the physician prescription, my student's medicine will be dispensed according to school's dispensing times: Morning, Afternoon, or Evening. I am aware that all medications that are ordered for ONLY ONCE A DAY will be administered in the MORNING unless otherwise specified on the prescription. I am aware that if DAW (Dispense As Written) or BRAND is not indicated, GENERIC medication will be dispensed. Total Number of Prescriptions Enclosed (Uploaded)*Please enter a number from 1 to 50.Consent* I agree to the following:I acknowledge that I am responsible for the cost of any medication not covered by my Medicaid/insurance company, for any medication the pharmacy cannot get reimbursed for or reimbursed their cost for, as well as any co-payments and deductibles, which I agree will be billed directly to my credit card by the pharmacy. If I am submitting insurance information, I agree to authorize the pharmacy to contact my insurance company for insurance verification, billing and collections for my child's medications. Our licensed pharmacies are HIPPA compliant and all personal information received will be solely maintained fore the purpose of dispensing medication and insurance collection. I acknowledge that I will pay a LATE FEE of $25 and corresponding delivery fees if above required items are not received 30 days prior to my student's start date.