Required Patient Summary Application Form

Please provide the following contact information.

All information except Work Phone  is required.

	About You
First Name
Last Name
Street Number
Street Name
Suite / Apt #
City
Province
Postal Code
Country
Work Phone Area Code
Work Phone
Home Phone Area Code
Home Phone
Year Of Birth (e.g. 1950)
Sex	F M
Weight	lbs. kgs. (specify lbs. or kgs.)
Height	cm ft/in (specify feet/inches e.g. 5/10. or cm.)
E-mail address	(not Hotmail or another alias email address.)
	About Your Pharmacy
Your Pharmacy's Name	CLICK HERE TO CHOOSE YOUR PHARMACY AJAX Discovery Bay 570 Westney Rd S Ajax Pharma Plus 240 Harwood Ave S Ajax ANCASTER Shoppers 47 Wilson St W Ancaster AURORA Care 24 Orchard Hts Blvd Aurora Sparkle 14800 Yonge St Aurora BARRIE Shoppers 279 Yonge St Barrie BOLTON Bolton Medical Centre 12295 Hwy 50 Bolton BRACEBRIDGE Shoppers 248 Manitoba St Bracebridge BRADFORD Pharma Plus 4040 John Steet W, Bradford BRAMPTON Bestgate 40 Finchgate Blvd Brampton Guardian Southgate 700 Balmoral Dr Brampton Heart Lake IDA 230 Sandalwood Pky E Brampton Kings Cross 17 Kings Cross Rd Brampton North Bramalea 9780 Bramalea Rd Brampton Peel 7700 Hurontario St Brampton Queen Lynch 157 Queen St E Brampton Thistle 332 Main St N Brampton BURLINGTON Shoppers 470 Appleby Line, Burlington, ON L7O 2Y2 GUELPH Shoppers 161 Silvercreek Pky N Guelph Shoppers 275 Eramosa Rd Guelph HAMILTON Barton-James Shoppers 275 James St N Hamilton Dell Pharmacy 327 Barton Street E. Hamilton, ON L8L 2Y2 Pharma Plus 869 Barton St E Hamilton Pharma Plus 969 Upper Ottawa St Hamilton HUNTSVILLE Shoppers 1 King William St Huntsville KING CITY King Centre 2075 King Rd King City LINDSAY Shoppers 74 Kent St W Lindsay MARKHAM 16th Avenue 1 Mintleaf Gate Markham Bridle Trail 9249 Kennedy Rd Markham Main 5293 Hwy 7 Markham Meadowbrook Lane 4591 Hwy 7 Markham MILTON Milton IDA 497 Laurier Ave Milton Shoppers 265 Main St E Milton MISSISSAUGA Airport Pharmacy 7460 Airport Rd Mississauga Apple-Hills 1221 Bloor St Mississauga, Carl's 1207 Hurontario St Mississauga Central Parkway 1300 Central Pky W Mississauga Chase 1675 The Chase Mississauga Churchill Unit 13 3105 Winston Churchill Blvd Mississauga City Centre 3420 Hurontario St, Mississauga City 134 Dundas St W Mississauga Cliffway 2021 Cliff Rd Mississauga Cooksville 3033 Hurontario St Mississauga Courtesy 1603 Clarkson Rd Mississauga Credit Valley 2000 Credit Valley Rd Mississauga Creditview 4040 Creditview Rd Mississauga Derry Road 3530 Derry Rd E Mississauga Dixie Village 3615 Dixie Rd Mississauga Kingsbridge 20 Kingsbridge Garden Cir Mississauga Lighthouse 223 Lakeshore Rd E Mississauga Meadowvale 6750 Winston Churchill, Mississauga Pharma Plus 1375 Southdown Rd Mississauga Pharma Plus 100 Queensway W Mississauga Rathburn 592 Rathburn Rd W Mississauga Shoppers 700 Burnhamthorpe Rd E Mississauga Shoppers 3200 Erin Mills Pky Mississauga Shoppers 6855 Meadowvale T. Centre Cir Mississauga Shoppers 2225 Erin Mills Pky Mississauga Shoppers 228 Lakeshore Rd W Mississauga Shoppers 1865 Lakeshore Rd W Mississauga Shoppers 4141 Dixie Rd Mississauga Woodland Village 3353 The Credit Woodlands Mississauga NEWMARKET Davis Drive 291 Davis Dr Newmarket Quaker Hill 16925 Yonge St Newmarket OAKVILLE Abbey - 1131 Nottinghill Gate, Oakville Fairways - 1500  Upper Middle W., Oakville Halton - 1060 Speers Road, Oakville Madill Pharmacy 331 Sheddon Ave. Oakville Pharma Care 1107 Lorne Park Rd Mississauga Pharma Plus - 511 Maple Grove Rd. Oakville Shoppers 520 Kerr St. Oakville ORANGEVILLE Jeffers' 185 Broadway Ave Orangeville Rolling Hills 140 Rolling Hills Dr Orangeville P 519 942 2225 ORILLIA OSHAWA Central 211 Simcoe St S Oshawa North Oshawa 1400 Ritson Rd N Oshawa PETERBOROUGH Shoppers 645 Lansdowne St W Peterborough PICKERING Bay Ridges 1235 Bayly St Pickering Liverpool 715 Krosno Blvd Pickering Pickering Sq 1450 Kingston Rd Pickering RICHMOND HILL Allencourt 610 Major MacKenzie Dr E Richmond Hill Bayview Hill 420 Hwy 7 E Richmond Hill Oakridges IDA 13075 Yonge St Richmond Hill PharmaPlus 9325 Yonge St Richmond Hill Richmond Hill 328 Hwy 7 E Richmond Hill STOUFFVILLE Stouffville IDA 6212 Main St Stouffville TORONTO Agincourt IDA 4245 Sheppard Ave E Scarborough Dale's - 310  Queen Street E. Toronto Bay 176 Yonge St Toronto Beach 2198 Queen St E Toronto Bloor West Village 2262 Bloor St W Toronto Bloor-Dundas 2333 Dundas St W Toronto Bridletown 3443 Finch Ave E Scarborough Chelsea 1180 Victoria Park Ave East York Don Valley 855 Broadview Ave Toronto Etobicoke Centre 40 Westmore Dr Etobicoke Forest Hill 393 Spadina Rd Toronto Guildview 4160 Kingston Rd Scarborough Habers Rosedale 600 Sherbourne St Toronto Pharmaplus Islington 4 Burnhamthorpe Rd Etobicoke Keele-Sheppard 3306 Keele St North York Kennedy Road 2 Antrim Cres Scarborough Malvern IDA 27 Lapsley Rd Scarborough Old Mill 2489 Bloor St W Toronto Pleasant View 2760 Victoria Pk Ave North York Port Union 5550 Lawrence Ave E Scarborough Scarborough 2296 Eglinton Ave E Scarborough Thorncliffe 65 Overlea Blvd Toronto West Hill 4410 Kingston Rd Scarborough York Downs - 3910 Bathurst Ave. North York WHITBY Pharma Plus 3555 Thickson Rd N Whitby Pringle Creek 728 Anderson St Whitby
	If Your Pharmacy Is Not Listed Please Complete The Following
Pharmacy Name
Pharmacy Area Code
Pharmacy Phone Number
Your Pharmacy's FAX
	About Your Doctor
Dr.'s First Name
Dr.'s Last Name
Practice Name
Your Dr.'s Street #
Street Name
Suite #
Doctor's City
Doctor Province
Dr. Phone Area Code
Dr.'s Phone
Dr.'s FAX

I am 18 years of age or older. No Yes

I agree to become a Patient of Ontario for the purpose of this or other medical consultations and agree to be bound by the rules and regulations and laws governing this.  No Yes

I have read and agree to the Terms & Conditions found in the Legal section of this website. No Yes

Are you pregnant?  No Yes

Are you nursing?     No Yes

I understand that if approved, I will be charged a non-refundable annual fee of $25 to participate in this program.   No Yes

Type Your First & Last Name To Confirm Agreement.