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

Last Name:
 First Name:
Date of Birth:
Day Month Year 		Delivery Address:
City:
 Province:
Postal Code:
 Special Delivery Instructions:
Home Phone Number:
 Work Phone Number:
Email Address:
Family Doctor:
 Drug Allergies:


Current Medications:

Family Member(s) Profile

1. Name:



Date of Birth:
Day Month Year 		Doctor:

Drug Allergies:

Current Medications:
2. Name:



Date of Birth:
Day Month Year 		Doctor:

Drug Allergies:

Current Medications:
3. Name:



Date of Birth:
Day Month Year 		Doctor:

Drug Allergies:

Current Medications:
4. Name:



Date of Birth:
Day Month Year 		Doctor:

Drug Allergies:

Current Medications:
5. Name:



Date of Birth:
Day Month Year 		Doctor:

Drug Allergies:

Current Medications:

How did you hear about Pharmex Direct?

How did you hear about us?
FriendEmployerWeb SearchOther

If employer/other, please specify:

Request for Prescription Transfer (Optional)

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


Fill prescription immediatelyHold on File

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.