First Name*Last Name*SeparatorDate of BirthSexMaleFemaleSplitterYour address? (This address can be changed later according to your delivery preferences.)SplitterYour delivery preference?In person to youIn person to any family memberBy the doorSplitterAre you currently pregnant, or breastfeeding?YesNoNot ApplicableWould you like to tell us more?SplitterList all major medical conditions:SplitterDo you have any allergies or intolerance to any medication / food?SplitterDo you smoke? (Including: cigarettes, cannabis, etc.)SplitterTo identify yourself, please take a picture of your health insurance card. If you do not have it with you, no worries as we will get that information at a later stage.Alternatively, you can enter your RAMQ number below:SplitterIf you have a private health insurance, please take a picture of your card. If you do not have it with you, no worries as we will get that information at a later stage.Alternatively, you can enter your private insurance number below:SplitterIf available, please upload your prescription:SplitterDo you accept that a pharmacist from our team contact your current pharmacy to transfer your prescription?I acceptI do not acceptSubmit Error occured. Please confirm your data and submit again:
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