Forms and Documents

This page explains SVdP Pharmacy’s application process in more detail.

 

To view a brief explanation of each form’s purpose, or to download individual forms (PDF), scroll down to view the list below.

To download a complete application, click the button(s) on the right.

Service at St. Vincent de Paul Pharmacy

Instructions on how to apply for service and which forms of ID and documentation you will need.

Patient Information Form

This form collects basic information about the patient’s demographics, household, health and medication needs. Also included on page 3 is a Consent to Treatment by Volunteers section which explains that many of the staff who provide care at our pharmacy are not paid.

Every applicant or patient must complete this form.

Monthly Income Detail

SVdP Pharmacy serves low-income residents of North Texas who have a total annual household income of 200 percent of the Federal Poverty Guidelines or less for their household size. This form collects information about a patient’s household income in order to verify that they meet this criterion for service.

Every applicant or patient must complete this form.

Terms of Service Agreement

Acknowledgement of several conditions for service at SVdP Pharmacy. 

Every applicant or patient must complete this form.

Monthly Expenses and Acknowledgement of Support

Details about monthly expenses and how the applicant covers them or who covers them for the applicant, if they receive assistance.

Applicants who are not employed, have no income, and who receive help to cover their living expenses must complete this form. If the applicant is employed and able to verify their income, they do not need to submit this form.

Homeless Shelter Referral Letter

A form letter which verifies that the applicant is homeless and cannot verify their residence.

In the case that an applicant is homeless or unable to verify their residence because they live under someone’s care, this form must be completed by the individual, organization or advocate who provides housing support.

 

Are you a practitioner or clinician who is assisting a patient? 

Do you have further questions?

 

Call us: (469) 232-9902