My Camper's Medication Has Changed Form

If your Camper's medication has changed, please submit this form. Complete a separate form for each camper. If you have any questions, call us at 1 (951) 407-0707.

LIST ALL the medications your camper will be taking at camp, since this form will invalidate the previous form you submitted. In this form, you will also have the option to enter insurance information if your insurance has changed. Make sure either you, or your physician send all prescriptions to Perris Hills Pharmacy.

Download the PDF version of My Camper's Medication Has Changed here.

PARENT OR LEGAL GUARDIAN INFO

First name: (required)

Last name: (required)

Email: (required)

Home phone number: (required)

Mobile number: (required)

MY CAMPER'S INFO

The information of the child going to camp

First name: (required)

Last name: (required)

Date of Birth: (required)

Month

Day

Year

MY CAMPER'S MEDICATIONS

Please list all medications (prescription, OTC, vitamins and supplements) that the camper is currently prescribed or is taking. Make sure you review your camper's Rx with your physician to confirm it is written exactly the way your camper takes the medication before sending to Perris Hills Pharmacy. We understand that this list might change as we approach camp season.

MEDICATIONS PRESCRIBED BY: Primary Physician
Enter all medications prescribed by your child's primary physician.

MEDICATIONS PRESCRIBED BY: Other Physicians
Enter all medications prescribed by other physicians (that are not your child's primary physician). Make sure to add Physician's first name, last name, phone number and fax for each medication

SPECIAL INSTRUCTIONS

Any special instructions?

Or notes you might like to add.

Has your insurance also changed?

INSURANCE INFORMATION

Please leave fields blank that do not apply.

Primary Insurance

Insured full name:

Insurance name:

Insurance phone #:

Member ID:

Rx BIN:

Rx PCN:

Rx GROUP:

Do you have secondary insurance?

Secondary Insurance

Insured full name:

Insurance name:

Insurance phone #:

Member ID:

Rx BIN:

Rx PCN:

Rx GROUP:

A G R E E M E N T
By clicking "Submit" you agree to Perris Hills Pharmacy's, My Kids Camp Meds TERMS OF USE and PRIVACY POLICY AGREEMENT.

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