Boynton Pharmacy Intake & Transfer Form

Boynton Pharmacy

Intake & Transfer Form

Welcome to Boynton Pharmacy!

You may use this form to:

Become a new patient at Boynton Pharmacy
Request us to transfer your medications to Boynton Pharmacy
Update your contact information including chosen name and pronouns at Boynton Pharmacy

If your prescription does not have refills to transfer, please contact your provider to request a new prescription be sent to Boynton Health Pharmacy in Minneapolis.

We ask one business day for the transfer process to be completed. 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.

Thank you!

Boynton Pharmacy Staff

410 Church St SE, N300

Minneapolis, MN 55455

612-624-7655

boynton.umn.edu/pharmacy

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

How did you find out about Boynton Pharmacy?*

Select or enter value

Patient Request*

Current patient means you have picked up prescriptions from Boynton Pharmacy in the past two years.

Select

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.

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.

Other medications including doses*

Please list all other current medications (not already filled at Boynton or being transferred in), including the dose of each if possible.

No other medications? Type "None"

This info will help us evaluate potential drug interactions.

Current Medications*

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

No current medications? Type "None"

This info will help us evaluate potential drug interactions.

Dose acknowledgement*

Select or enter value

Student Account Authorization

If applicable

Select

Notification Acknowledgement*

Select

Patient Education Preference*

Help us "Go Green" by selecting paperless patient education. Our labels all have a QR Code which you can scan with your phone camera for patient education and help us save paper.

Select or enter value

Pharmacy Name

Pharmacy Phone Number*

What pharmacy should we call to transfer your Rx(s) to Boynton Pharmacy?

Phone

Pharmacy City & State*

Pickup Preference*

Select or enter value

Complete Mailing Address*

Where in Minnesota or Wisconsin would you like this Rx order mailed? Please note: once a prescription has been processed for mailing, you cannot pick it up at the pharmacy. Please plan ahead as mailing may take 5-7 days.

Mailing Fee Acknowledgement*

Select or enter value

Rx #1 to transfer:*

Please list prescription medication name. strength and Rx number (if available) you are requesting to be transferred to Boynton Pharmacy.

Rx #1: fill or hold?*

Select or enter value

Rx #2 to transfer:

Please list prescription medication name. strength and Rx number (if available) you are requesting to be transferred to Boynton Pharmacy.

Rx #2: fill or hold?

Select or enter value

Rx #3 to transfer:

Please list prescription medication name. strength and Rx number (if available) you are requesting to be transferred to Boynton Pharmacy.

Rx #3: fill or hold?

Select or enter value

Rx #4 to transfer:

Please list prescription medication name. strength and Rx number (if available) you are requesting to be transferred to Boynton Pharmacy.

Rx #4: fill or hold?

Select or enter value

Other

Anything else we need to know? You can list additional Rx's to transfer or other info here if needed.

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