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Full Name

First NameLast Name

Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityProvince

Postal Code

Date of Birth

Date

Allergy Confirmation

Documents Upload

Like image of the skin condition etc.

What date and time work best for you?

Any other specific date and time, if the above selection is not suitable.

Date

Hour MinutesAM/PM Option

What medication are you looking for or Please give us details on your condition?

Please select if any of these apply for your condition?

Would you like to be notified about promotional services?

Signature

By submitting this form, you acknowledge that the information provided is accurate and complete to the best of your knowledge. This form is intended solely for the purpose of booking an appointment for a medication-related consultation and does not replace a direct consultation with a pharmacist or physician. Please note that any medication request or recommendation will only be fulfilled after a full consultation, which may include a review of your medical history, current medications, and any necessary lab results. All personal health information provided in this form will be handled in accordance with the Personal Information Protection Act (PIPA) of BC and the College of Pharmacists of BC’s standards on patient confidentiality. This form is not for emergency use. If you are experiencing a medical emergency, please contact 911 or your nearest healthcare facility. The pharmacy reserves the right to decline or reschedule appointments if necessary. You may also need to adapt this further based on the specific policies of your pharmacy or the scope of services you offer. Let me know if you need any additional modifications!

Payment Amount

CADVirtual Minor Ailment Fee: $25

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