Rida's Pharmacy PharmaChoice Enrollment Form
Rida's Pharmacy
6 Stevens Avenue, Marathon ON P0T2E0
807-232-8090
Patient Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Other
Healthcard Number
Photo of Healthcard
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email
example@example.com
Allergies
Medical Conditions
Insurance Information (if applicable)
NHIB Status / Number
Photo of NHIB Card
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Private Insurance 1 #
Photo of Private Insurance 1
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Private Insurance 2#
Photo of Private Insurance 2
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Private Insurance 3 #
Photo of Private Insurance 3
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Prescription Transfer
Would you like us to transfer your medications / profile?
*
Please Select
Yes
No
If yes, which pharmacy is your current pharmacy?
Current pharmacy phone number
Please enter a valid phone number.
Privacy and Consent
I hereby authorize Rida's Pharmacy to collect, use, and disclose my personal and health information for the purpose of providing pharmacy services. I understand that my information will be kept confidential and used in accordance with applicable privacy laws.
Patient Signature
*
Date
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Month
-
Day
Year
Date
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