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.
Gender*
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Health Information

Allergies

Medical Conditions (Check all that applies)

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Preferences

Medical Instruction Language
Packaging
Brand

Insurance Information

PharmaCare
Max. file size: 100 MB.
Insurance

Upload Your Prescription

Max. file size: 100 MB.
Accepted file types: pdf, Max. file size: 100 MB.

Delivery Options

Select Store Location

We will email you a payment link for your presecription, a receipt and pickup/delivery method once we have processed your information.

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