Boynton Pharmacy Emergency Contraception (EC)Request Form

Boynton Pharmacy

Emergency Contraception (EC)

Request Form

Welcome to Boynton Pharmacy!

You may use this form to request emergency contraception to be billed to your insurance. Please note:

If you waiting for this request in the pharmacy, please alert a cashier so we can process your request right away
Insurance coverage requires the product must be for your own use
We will send you a text (or RXLOCAL app notification) when your order is complete. Haven't received a message? Give us a call and we will check the status
Picking up for someone else? You may purchase EC over-the-counter at Boynton Pharmacy ($19.99)

We ask one business day for your non-emergency emergency contraception order to be completed. If your request is more urgent, please call Boynton Pharmacy to find out how soon we can fill your order.

Need EC after hours? It is available at the following campus vending machines:

East Bank: basement vending machine at Coffman Memorial Union
St. Paul Campus: Ruttan Study Space, Ground Floor
West Bank: Lower level of Willey Hall
Find maps and more information on birth control at boynton.umn.edu/birth-control

Thank you!

Boynton Pharmacy Staff

410 Church St SE, N300

Minneapolis, MN 55455

612-624-7655

boynton.umn.edu/pharmacy

Hours: M, T, W, F | 7:45 a.m. to 4:30 p.m. Th | 8:30 a.m. to 4:30 p.m. | Closed University Holidays

First Name*

Given or chosen first name

Last Name*

Given or chosen last name

First name used on Legal Documents

**Leave blank if this is the same as above.

Last name used on Legal Documents

**Leave blank if this is the same as above.

Date of Birth*

UMN Student/Employee ID

If applicable

Primary Phone Number*

Cell phone is preferred as we can then send you an "Rx Ready" notification when your order is ready.

Phone

Phone Type*

Select or enter value

Email*

Rx Insurance*

Select or enter value

Billing Address*

Address associated with your prescription insurance.

City*

Billing address city

State*

Billing address state abbreviation (2 letters)

Billing Zip Code*

Zip Code associated with your Rx insurance.

Current or New Patient*

Please select "new patient" unless you are sure you have filled prescriptions at Boynton Health Pharmacy in the past two years and haven't had any changes to your address or other demographics.

Select or enter value

Sex*

Sex associated with prescription insurance (or legal documents if uninsured)

Select or enter value

Gender Identity

optional

Pronouns

optional

Drug Allergies*

Please list any drugs you are allergic to and your reaction to the medication.

Type "None" if you do not have any allergies.

Current Medications*

Please list your current medications, including the dose of each if possible.

No current medications? Type "None"

Fill all of your prescriptions at Boynton Health Pharmacy? Type "current"

This info will help us evaluate potential drug interactions.

Dose acknowledgement*

Select or enter value

Notification Acknowledgement*

Select

Patient Education Acknowledgement #1*

Boynton Pharmacy can only bill your insurance for emergency contraception (EC) for yourself. If this request is for someone else, please purchase EC over-the-counter.

Select

Patient Education Acknowledgement #2*

Select

Patient Education Acknowledgement #3*

Select

Patient Education Acknowledgement #4*

Select or enter value

Patient Education Acknowledgement #5*

Select or enter value

Patient Education Acknowledgement #6*

Select

Patient Education Acknowledgement #7*

Select

Patient Education Acknowledgement #8*

Select

Patient Education Acknowledgement #9*

Select

Electronic Signature*

Please type your name here to electronically sign your request for emergency contraception. Thank you!

Other

Anything else we need to know? You can request pregnancy tests (2-pack) or other OTC's here. To browse a selection of our retail items, visit https://z.umn.edu/otc-order-form

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