* = Required Information
Patient Details
First Name
*
Last Name
*
Date of Birth
*
Phone Number
*
Address
*
City
*
Canadian Province
*
Please select canadian province
Ontario
Quebec
British Columbia
Alberta
Manitoba
Saskatchewan
Nova Scotia
New Brunswick
Newfoundland and Labrador
Prince Edward Island
Northwest Territories
Nunavut
Yukon
Zip/Postal Code
*
Pharmacy Name
*
Pharmacy Phone
*
Prescriptions to be transferred
If you would like to transfer all prescriptions, simply check the box below.
Transfer all my prescriptions
If you would like to selectively transfer your prescriptions, simply start typing to find your medication.
List specific prescriptions to be transferred
MEDICATION NAME
Rx1 Med Name
Rx2 Med Name
Rx3 Med Name
Rx4 Med Name
Rx5 Med Name
PRESCRIPTION NUMBER
FROM CURRENT PHARMACY
Rx 1 #
Rx 2 #
Rx 3 #
Rx 4 #
Rx 5 #
Submit