Patients

New Patient Information

Thank you for choosing College Pharmacy to fill your compounding needs! When choosing a compounding pharmacy, both price and quality of formulations are major factors in determining your selection. To this end, College Pharmacy strives to maintain competitive pricing while maintaining the high standards of quality that have established us as an industry leader for over 40 years. It is the compounding process, attention to detail, regulatory compliance, and the quality of the compounding components that continues to make our formulations exceptional.

College Pharmacy’s compounding practices are both USP 795 and 797 compliant. Our testing protocol includes: Potency, Sterility, Endotoxin, and Fungal testing. Our sterile formulations are compounded in a state-of-the-art clean room and ISO 8 compounding lab that was fully renovated and updated in the summer of 2014.


Important Information & Required Forms For Signature

The following forms must be printed, completed, and returned to College Pharmacy before we can process your prescription:

In order to view and print these forms, you will need the free Adobe® Acrobat® Reader™ plugin. If you do not have it installed, you can download it for free by CLICKING HERE


Directions: Please print, complete and return the forms to College Pharmacy. Questions? Please call our New Patient Representative at (800) 888-9358 ext. 107.

Email: newpatient@collegepharmacy.com

Fax: (800) 556-5893 / (719) 262-0035

Mail: While you can mail us your completed forms, we cannot proceed with compounding your prescription until we have received the signed documents. Mailing the forms will delay your prescription processing.

College Pharmacy
3505 Austin Bluffs Pkwy. Suite #101  
Colorado Springs, CO 80918


New Patient Registration Form

By providing the following information, you will allow our pharmacists to process your prescription requests more efficiently. Please be sure to fill in as much information as you can and please note that all fields that are colored RED are required for you to submit this form. If you have any questions, please contact our New Patient Representative at newpatient@collegepharmacy.com, or call us at (800) 888-9358 x107.

 
Personal Information
Full Name:
Mailing Address (no P.O. Boxes):
Additional Mailing Address:
City:
State:
Zip Code:
Country:
Home Phone Number:
Work Phone Number:
Mobile Phone Number:
Date of Birth (MM/DD/YY):
Please List Your Allergies:
Please List Your Medical Conditions:
Email Address:
Authorized Contact 1 - Information
Contact Name:
Contact Phone Number:
Contact Relation:
Authorized Contact 2 - Information
Contact Name:
Contact Phone Number:
Contact Relation:

Method of Payment
A College Pharmacy representative will call you to confirm your payment information. Please describe the best method of contact below:
Method of Contact:
Preferred Method of Payment:
Check (note that this will delay the order until we receive the check)
Credit Card (A customer service representative will contact you directly to verify your contact information and set-up credit card payment.)

Prescription Information
Please give us the details of how we should contact you to inform you concerning the cost of your medication. If by phone, please provide a private number where we may leave a detailed message. If you have any questions regarding your medication, please contact College Pharmacy during business hours.

College Pharmacy Policy and Procedure
I understand that once I authorize College Pharmacy to start compounding my prescription I am responsible for payment in full, even if I cancel my order later. I understand that I am not only purchasing a compounded preparation, but a specialized service as well. Yes No
I understand that I may request a quantity other than what was written by my doctor, unless limited by insurance or if the prescription requires prior approval from my doctor. Yes No
I understand that College Pharmacy recommends ordering smaller quantities if chemical sensitivities may be an issue, and pharmacists are available discuss prescriptions during business hours. Yes No
I understand that it is my responsibility to contact College Pharmacy within 24 hours of receiving my package if there is an error or any damage. Yes No
I understand that College Pharmacy cannot accept returns on any custom compounds or commercial prescription products. Regulations prohibit the return and resale of such items and require a strict “No Return” policy. Yes No
I understand that College Pharmacy will fill and ship any prescription received from a Prescriber and it will be billed to the method of payment on file, unless I specify otherwise. Would you like to be called any time a prescription is called in to College Pharmacy? Yes No
I understand that I am responsible for updating my information with College Pharmacy, and that College Pharmacy is not responsible for any fees, damage, or loss associated with old information, even if the order is not placed by the patient. Yes No
I understand that a pharmacist is available to answer my questions between 8:30 am and 6 pm MST at 800-888-9358. Yes No

Shipping Information
Please Note: if you select "No" to the following question, please provide an alternate "ship to" address below, OR you may download the signature release form and agree to the conditions on that form for packages to be left without a signature. To download the signature release form, please CLICK HERE.
Will someone be available at your address to sign for packages?
Alternate Ship To Address
Is this address residential or business?
Ship Care Of:
Ship To Address (no P.O. Boxes):
Additional Ship To Address:
City:
State:
Zip Code:
Date You Need the Prescription:
(Please note that College Pharmacy is a compounding pharmacy, and your prescription may require several days to prepare, in addition to transit time.)
Most prescriptions are shipped third business day. Upon request, we can ship second business day or overnight. Some prescriptions require special overnight on ice handling. In certain areas, early morning and Saturday delivery may be available for an additional charge. To access our current rates, click on "Shipping Information" on the "Pharmacy Services" dropdown menu. You may also call us directly for a quote specific to your prescription.
Additional Comments: