First Name (required)

Last Name (required)

Phone Number (required)

Email (required)

Upload a clear photo of your prescription

Please note: you must bring the original prescription to the pharmacy upon pickup or delivery!

All new prescriptions are subject to the pharmacist professional judgement, the Ontario College of Pharmacists Code of Ethics and the Pharmacy Standards of Practice & By-Laws

Pick-up / Delivery Date (Required)

Pick-up / Delivery Time (Required)
---MorningAfternoonEvening

Would you like your prescription(s) to be delivered? (required)
YESNO

Comments

I agree and consent to the Prescription Refill Terms and Conditions and the Privacy Policy

First Name (required)

Last Name (required)

Phone Number (required)

Email (required)

Prescription Number 1

Prescription Number 2

Prescription Number 3

Prescription Number 4

Pick-up / Delivery Date (Required)

Pick-up / Delivery Time (Required)
---MorningAfternoonEvening

Would you like your prescription(s) to be delivered? (required)
YESNO

Comments

I agree and consent to the Prescription Refill Terms and Conditions and the Privacy Policy

Patient information

First Name (required)

Last Name (required)

Phone Number (required)

Email Address (required)

Pharmacy Information

Your Current Pharmacy Name (required)

Your Current Pharmacy Phone (required)

Your Current Pharmacy Address (required)

We need this information to contact your pharmacy on your behalf and transfer all prescriptions you need to Erin Centre Pharmacy

Prescriptions you need to be transferred

Enter the name and /or the prescription numbers of all prescriptions you would like to transfer to us

Would you like to transfer all your prescription? (required)
Yes, transfer all my prescriptions

Prescription Number 1 (required)

Prescription Number 2

Prescription Number 3

Prescription Number 4

Pick-up / Delivery Date (Required)

Pick-up / Delivery Time (Required)
---MorningAfternoonEvening

Would you like your prescription(s) to be delivered? (required)
YESNO

Comments

I agree and consent to the Prescription Refill Terms and Conditions and the Privacy Policy