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   COLBY COLLEGE STUDENT FACE SHEET

Phone: (207) 872-7979 • Fax (207) 872-7922 • Email winslowrx@yahoo.com

Full Name: _______________________________ __ Date of Birth: _  _  _/_      / _        

Address: _________________________________________________________       __

________________________________________________________________     ___

Student Phone: ___________________________________________________     ___

Allergies (If any): __________________________________________________     __

Which Delivery Time?        12:30 – 1:00pm             OR             5:00-5:30pm

Insurance information

Name of Insurance: ________________________________________ __________

ID: ___________________________________________________________ _____

Rx Bin: ________________________ Rx PCN: ________________________ _____

Rx Group: __________________________Pharmacy/Provider #:                                                    

Payment Information

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

Name on Card:

Credit Card #: – – –

Expiration: / CVV (Code on reverse):

*Any OTC items to include:

*Interested in transferring maintenance meds from another pharmacy?

Current Pharmacy:       Phone #:

Medications:          

*Questions on the prescribed med? Have you taken this med previously? Talk w/ Pharmacist?