Forms & Documents
See below for links to our online forms and important downloadable documents. When completing one of our online forms, we recommend using a device with a touchscreen so that you can use your finger to sign (but a laptop or desktop computer works, too).
Having trouble accessing or need a hard copy of one of our online forms? Send us a message here.
A quick how-to for our online forms
All of our online forms are hosted through Jotform, a HIPAA-compliant form software. To complete one our Jotforms, start by clicking on the appropriate link below and then fill out the form’s fields by typing, clicking, etc. Please read question carefully and be sure to input correct information (e.g., we often have patients accidentally submit their date of birth, set the expiration date as the current date, or use a nickname instead of their legal name); forms that are submitted with incorrect information will need to be resubmitted. Questions with a red asterisk (*) are required in order to submit a form. Please also note that forms can only be submitted by the patient or a legal guardian/Power of Attorney (e.g., your spouse can’t submit a form on your behalf just because you gave them permission to).
Most of our forms will serve as a legally binding document that requires an electronic signature before submitting, which can be done either by signing with your finger (on a device with a touchscreen) or holding down the left click button on your mouse and dragging your cursor across the signature field (on a device without a touchscreen). If you have difficulty signing electronically, let us know and we can send you a hardcopy version of the form you’re attempting to complete instead.
HIPAA Notice of Privacy Practices
Describes our privacy practices and the rights you, the individual, have as they relate to the privacy of your Protected Health Information (PHI)
Immunization Screening & Consent Form:
COVID
A fillable consent form for COVID vaccine appointments
Formulario de consentimiento y examen de la vacuna COVID (Spanish)
Un formulario de consentimiento rellenable para las citas de vacunación contra la COVID
A fillable consent form in Spanish for COVID vaccine appointments
Immunization Screening & Consent Form:
All Non-COVID Vaccines
A fillable consent form for all non-COVID vaccines
MAP My Meds
A fillable PDF flowchart you can use to keep track of your daily medication regimen
Name & Gender Recognition Policy
Describes our standard procedure regarding transgender, transitioning, and gender non-conforming patients whose legal name and/or sex do not accurately reflect their gender identity
New Patient Intake Form
Intake form for new patients that haven’t filled a prescription or received a vaccine at St. Paul Corner Drug. After completing this form, please give us a call so that we can further assist you.
note: Starting November 1st, 2022, we have paused the addition of new prescription patients for the foreseeable future (click here to learn more). Please only complete this form if you have an immediate family member already filling prescriptions with us or you’ve spoken to someone on our team.
New Patient Packet
Document detailing important information about our processes and policies for new patients
New Patient Waitlist
For prospective patients interested in filling their prescriptions at St. Paul Corner Drug
note: Adding your name to this Waitlist does NOT guarantee that you will be able to become a prescription patient at St. Paul Corner Drug.
Patient Authorization for
Release of Medical Information
Request form that can be completed by the Patient or a Patient Representative allowing St. Paul Corner Drug to be able to share PHI with individuals others than the Patient
Patient Authorization for
Self-Pay (HITECH)
Online form for patients who are a part of our Cost Plus self-pay program
Request for Medical Expense Report
Request form that can be completed by the Patient or a Patient Representative to receive a copy of the Patient’s medical expenses via mail or email (commonly used for filing taxes).
note: For pick up in person or curbside at the pharmacy, please make your request at the time of pickup rather than completing this form.
Request for Report of Medical Record
Request form that can be completed by the Patient or a Patient Representative to receive a copy of the Patient’s medical record
Request for Prescription Transfer
(from another pharmacy)
note: Currently, we are having difficulty transferring prescriptions from other pharmacies due to their staff shortages and other service issues. If possible, we prefer that your care provider send a new prescription order directly to our pharmacy. However, if this is not possible, you can complete this form and we’ll make our best attempt to transfer your prescriptions directly from your current pharmacy.
