SHCC@Shands Prescription Delivery

  • Permission to Deliver Prescriptions to SHCC@Shands

    I request that the SHCC Pharmacy fill the following prescription(s) and have them delivered to SHCC@Shands. The medication cannot be returned for credit or exchange.
    PLEASE NOTE: If not picked up within 48 hours of the date stated here, the medication will be restocked and I will be charged a $3 restocking fee. I authorize the Nurse in Charge to act as my agent in receipt of the medication, if delivered. I authorize release of information required to process insurance claims and/or bill this payment. The co-pay, which the UF Student Health Insurance Plan does not pay, and any other charges will be placed on my myUFL account.
    I understand that if I have medication-related questions I can call 1-866-941-1760 during regular business hours to speak to a pharmacist.
  • PLEASE NOTE: NEW prescriptions OR prescriptions that you wish to TRANSFER to the SHCC Pharmacy MUST BE CALLED IN (352-392-1760) OR FAXED (352-846-1521). We CANNOT fill them with this form.
  • Prescription & Patient Information

    Other - Please specify how many total packs you need.
    Other - Please describe drug allergies in detail.
  • Insurance Company Information

    Other - Insert name of insurance company AND complete the insurance policy information fields below.
  • Third Party Pick Up of Medications

    Please fill out below if you need a someone else to pick up your medication(s).
  • I authorize the person(s) named here to pick up my medication(s) and sign for the charges or release medical information for billing.
  • Confirmation of delivery to SHCC@Shands

    If you need a prescription filled at the SHCC Pharmacy in the Infirmary Building, please call (352) 392-1760.