Enrollment Form

This form provides Pharmex Direct with the information necessary to fill your prescriptions. For new prescriptions, have your doctor fax or phone
the prescription to us. If you already have a prescription, you may also mail it to us.

If you’d prefer, here is a printable version of our enrollment form which you can mail or fax to us. If you are an existing Pharmex
customer and require a repeat prescription, please use the repeat prescription form or contact us.
Note: Provincial law prohibits you from faxing your prescription to us directly.

Personal Information

First Name Last Name
Email Birthday
Address
City Province
Postal Code Special Delivery Instructions
Home Phone Number Work Phone Number
Family Doctor Drug Allergies
Current Medications

Family Member's Profile

Name
Doctor
Date Of Birth
Drug Allergies
Current Medications
Name
Doctor
Date Of Birth
Drug Allergies
Current Medications
Name
Doctor
Date Of Birth
Drug Allergies
Current Medications
Name
Doctor
Date Of Birth
Drug Allergies
Current Medications
Name
Doctor
Date Of Birth
Drug Allergies
Current Medications

How did you hear about Pharmex Direct?

How did you hear about us?

If employer/other, please specify:

Request for Prescription Transfer (Optional)

Pharmacy Name: Town:
Prescription Required (Name) and (Quantity):

By completing the section headed "Request for Prescription Transfer", I acknowledge that I have requested Pharmex Direct to have my medication records transferred from the above pharmacy. Please note: Narcotic prescriptions cannot be transferred - a new prescription will be required.

Upon confirmation of the above information, your patient file will be setup with Pharmex Direct Inc. Your records will be revised with every prescription, and an updated Pharmex Care Card will be provided to you.

Download Prescripton Form