Patient Health Profile PHO-100
 
First name  
Middle name  
Last name  
Affiliate Pharmacy-Online
Affiliate agent code
Birth Date  
(YYYY-MM-DD)
Weight  
(Lbs)
Gender Male
Female
Childproof Caps Yes
No
Allow generic substitutions Yes (unless otherwise stated by physician)
No
Current Medications Use the space below to list any medications that you are currently taking
(Drug name, strength and dosage)
 
 
 
 
 
 
Allergies Use the space below to list any allergies you have
 
 
 
 
Medical Conditions Use the space below to list any medical conditions that you have
 
 
 
 
Your primary physician's information
Physician's name:
Medical Center:
Street:
 
City:
State/Zipcode:
Phone:
Fax:
Payment Options Credit Card
Credit Card Card number:
Expiry date: MM/YY
Card holder's name:
Card number:
Shipping Address
Street:
 
City:
State/Zipcode:
Country:
Phone: (required)
Email:
Special shipping instructions:




Billing Address (if different than shipping address)
Street:
 
City:
State/Zipcode:
Country:


Use the space below to enter any other notes you may think our pharmacists should be aware of in regards to your medical profile:
 
 
 
 
 
 
 
 
 
 
 
 
Please mail this form to:
Extended Care Pharmacy Ltd. # 202, 6420 - 6A Street S.E. Calgary, AB CANADA T2H-2B7
phone: 1-866-266-9955 fax: 1-866-252-7137