Prescription Upload Form Acknowledgement Users will automatically agree to the following upon the submission of this prescription form: I understand that if my prescription is eligible for this service then the original Prescription must be provided at the time of prescription pickup. I understand that not all prescriptions will be eligible for this service, a pharmacy team member will contact me if my prescription is not eligible (e.g. From out of country doctor. Medication that are not available/offered by the pharmacy. Prescription already expired/written over one year ago. Forgery). I understand that a pharmacy team member may contact me when my prescription is ready (wait-time may vary). By submitting this form, I am consenting to the collection and use of my personal information for the purpose of submitting my prescription to be filled by the Pharmacy I have selected. I understand that my prescription and personal information will reside at the pharmacy I have chosen. First Name* Last Name* Phone*Email* Address*Gender* Male Female Other Date Of Birth* MM slash DD slash YYYY Personal Health Number*Health InformationAllergiesMedication Allergy (Specify Here) Food (Specify Here) Environmental Allergy (Specify Here) Any Other Allergies (Specify Here) Medical Conditions (Check all that applies)Untitled Allergy ADHD Arthritis Chronic Plan COPD Depression Diabetes Dementia Glaucoma Insomnia Osteoporosis Heart Failure High Cholesterol High Blood Pressure Kidney Failure PreferencesMedical Instruction Language English English & Chinese Packaging Child-Proof Vials Flip-top Vials Easy Open Snap Cap Compliance Packaging Brand Generic if available Brand if available Cheapest Option No Preference Insurance InformationInsurance Company Name PharmaCare Eligible Not Sure Third Party InsuranceMax. file size: 100 MB.Policy No. Client Id Carrier No Insurance Card Holder Spouse Child Upload Your PrescriptionUpload PhotoMax. file size: 100 MB.Upload PDFAccepted file types: pdf, Max. file size: 100 MB.Delivery OptionsSelect Store Location Burnaby Richmond Surrey Vancouver Pick Up In Person Deliver to Address Extra Delivery Instructions Delivery Time Preference We will email you a payment link for your presecription, a receipt and pickup/delivery method once we have processed your information.
