Carefully complete the registration form  information and click on the SEND button or mail to:

 If you require assistance, please call directly at:
1.877.525.6554
Registration Form


 
Last name
First name
Initials
Date of birth of (dd/mm/yyyy)
Home phone
Business phone
E-Mail address
Adress
City
Province
Postal code
If you are enrolling as part of a group plan, please provide:
 
Name of Employer
Organization or Provincial Plan
Group Plan #
Individual I.D. #
Spouse's information:
 
Last name
first name
Initial
Date of birth of (dd/mm/yyyy)

 
Dependent(s) information (if applicacble):
  
 
Name of dependent I

Date of birth of dependent I

Name of dependent II

Date of birth of dependent II

Name of dependent III

Date of birth of dependent III

 
Physician and medication:
 
Physician name
Physician Phone
 
Do you or any members of your family have any allergies?

 
Is any member of your family currently taking any prescription medications?

 
Approximately how many prescriptions has your family had  in the past 12 months?

 
For your convenience, select the best time to phone you to obtain the additional information necessary to complete your medication profile
  
 
 
Phone number
Day of week

Time

How did you first hear about us

Email Address?