Colby Face Sheet | Savage's Drug

Full Name*

Date of Birth*

Address*

City*

State*

Zip Code*

Student Phone*

Allergies (if any)

Delivery TimeMonday–Friday at 4:30pm

Name of Insurance*

ID*

Rx Bin

Rx PCN

Rx Group

Pharmacy/Provider #

(Any private information will be stored securely at Oakland Pharmacy, and never replicated or shared in any way.)

Name on Card*

Credit Card #*

Expiration (MM/YY)*

CVV (Code on reverse)*

Any OTC items to include?

Are you interested in transferring maintenance meds from another pharmacy? If yes:

Current Pharmacy

Phone #

Medications

Questions about your medications? Have you taken this med previously? Do you need to speak with a pharmacist? Let us know: