Student Registration - Keystone Pharmacy

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 some C2 prescriptions (Controlled Substances) due to the national drug shortage. Please contact Keystone Pharmacy directly to determine if the C2 your student is on is one that the pharmacy can get through their vendor. 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*

First Middle Last

Student DOB*

Student Date of Birth

Male / Female*

Male

Female

Medication Allergies*

Please list any allergies to medication (or write NONE if none exist)

Existing 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 Country

Phones*

Home Phone

Cell Phone

School*

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

Email of Parent*

Insured*

Insured Name (Subscriber)

DOB (Subscriber)

Prescription Plan*

Name of Prescription Plan

Prescription Plan Phone

Prescription Member Info*

Member/ID#

RxBin#

RxPCN#

RxGroup#

Secondary Insurance (If Applicable)

Secondary Insurance

Secondary Insurance Phone

Secondary Insurance Member (if applicable)

(2nd) Member/ID#

(2nd) RxBin#

(2nd) RxPCN#

(2nd) RxGroup#

Pharmacy

Current Pharmacy Name

Phone Number

Billing Address (if different than home address)

Street Address Address Line 2 City State ZIP Code

Please 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.

Please Upload Prescriptions Card Here (Front AND Back Please) - PDF or JPG

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