Step 1: Keystone Professional Pharmacy - Student Registration Form

Keystone Professional Pharmacy Student Registration Form. Please include copy of your Prescription and both sides of Prescription Insurance Cards.

PLEASE NOTE: Keystone Pharmacy and our Services below are unable to fill C2 prescriptions (Controlled Substances) due to the national drug shortage. We also do not fill Inhalers, EpiPens, Injectables, Growth Hormones, Birth Control Prescriptions, or Acne Meds topicals and gels. There is no need to register a student with KPP if they are not taking an oral solid dosage form prescription or OTC medication. Do not proceed nor register if you only need the above services, as we cannot fill these requests.

"*" indicates required fields

Student Name*
Student Date of Birth
Male / Female*
Please list any allergies to medication (or write NONE if none exist)
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 Phone
Cell Phone
Name of School
Location of School (State)
Please provide additional details if School is unknown or there are different circumstances.
Start Dates*
Medication or School START Date
Medication or School END Date
Insured Name (Subscriber)
DOB (Subscriber)
Prescription Plan*
Name of Prescription Plan
Prescription Plan Phone
Prescription Member Info*
Secondary Insurance (If Applicable)
Secondary Insurance
Secondary Insurance Phone
Secondary Insurance Member (if applicable)
(2nd) Member/ID#
(2nd) RxBin#
(2nd) RxPCN#
(2nd) RxGroup#
Current Pharmacy Name
Phone Number
Billing Address (if different than home address)
Please Check the Following Items:*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB, Max. files: 5.
    Please upload as an Adobe PDF or JPG image: Front AND Back of Prescription Card