Minor Ailment Form Pharmasave Northwoods Village

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Personal Health Number* This field is required.Carecard number
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Phone* This field is required.
Area Code
Phone Number
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Birthdate * This field is required.
Month
Day
Year
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Please upload a picture of your health insurance (if available)We will also provide a receipt for you to claim manually if you do not have your health insurance card available. Please also present to the pharmacy staff.
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Select files to upload
Max. file size: 10.6MB
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Are you currently pregnant or breast feeding?* This field is required.
Pregnant
Breastfeeding
N/A
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Drug Allergies* This field is required.Please specify the severity of the allergic reaction.
Please write “No Known Allergies” if no drug allergies
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Do you have any Medical Condition(s)* This field is required.Please list all Medical Condition(s)
E.g: Medical history, medical status, medications, etc.
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Minor ailment of concern or contraception?* This field is required.Please only choose 1 minor ailment per request.We are only able to prescribe under the 21 minor ailments listed. For more information about minor ailments, please visit Minor Ailments
acne
birth control pills
cold sores
emergency contraception (Plan B)
eye infections
indigestion
fungal infections (skin or nail)
GERD
headache
hemorrhoids
impetigo
musculoskeletal pain
nicotine cessation
oral ulcers (canker sore)
oral thrush
seasonal allergies
shingles
skin rashes or irritation
threadworms and pinworms
urinary tract infection
urticaria, including insect bites
vaginal candidiasis
Not sure which condition
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Briefly describe your symptoms, including what worsens them, their severity, duration, and any other relevant details about your primary concern* This field is required.Please note the pharmacist is only able to prescribe under the 21 minor ailments. Please check the categories here: Minor Ailments
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Have you had a prescription for this condition previously?* This field is required.
YESNO
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If yes, please provide the product(s) name
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Comment or Message
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I confirm that I have provided all my health information on this form to the best of my knowledge.

I authorize a pharmacist at Pharmasave Lonsdale (1412061 BC Ltd.) to access and dispense medications according to my symptoms.

I authorize the Pharmacist at the Pharmacy to prescribe medications under Minor Ailments.
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Signature* This field is required.By signing below, I hereby attest that I confirm and agree to the information in this form. I attest the information provided is true and correct to the best of my knowledge and I give consent to Pharmasave Lonsdale (1412061 BC Ltd.) to assess and dispense any medications prescribed by the pharmacist.
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