First Name *

Last Name *

Email *

Phone *

Additional Patient Information

Pharmacy Name *

Pharmacy Telephone Number

Which medicines do you want us to transfer? You may also want to tell us about any details you feel we may need to know at this point.

Upload a clear pic snapshot of your current prescription label (if possible)

Upload Insurance Card (Primary) *if not used at previous pharmacy

Upload Insurance Card (Secondary spouse) *if not used at previous pharmacy

OHIP Card (health card) *If under 25 or over 65yo

What specialty products would you like our pharmacy to carry?

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Please follow up with within 24 hours via telephone- sometimes technology lets us down and the request gets "Hung up"

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Please follow up with within 24 hours via telephone- sometimes technology lets us down and the request gets "Hung up"

Constipation Treatment Decision Flow Chart