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.

Please scroll to the bottom of this page for a copy of the Agent Authorization for Transport of Documents form.

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 and Expense Detail

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

Every applicant or patient must complete this form with help from Pharmacy Staff.

Acknowledgement of Support for Monthly Expenses

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

Every applicant must complete this form, even if they cover all their own living expenses. For questions, ask Pharmacy staff for help!

Terms of Service Agreement

Acknowledgement of several conditions for service at SVdP Pharmacy. 

Every applicant or patient must complete 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.

 

Optional: Agent Authorization for Transport of Documents

In the event that a patient is unable to leave their home or otherwise travel to SVdP Pharmacy to submit their application for service, an agent or volunteer may transport these documents for them, along with a signed copy of this form.

 

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

Do you have further questions?

 

Call us: (469) 232-9902