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.