Form for an opening account

Your informations
Name*
First Last
Address*
Address City Province Postal Code
Email*
Phone number*
Birth date*
DD dash MM dash YYYY
Faites nous parvenir une photo de votre carte d'assurance maladie :*
Drop files here or

Max. file size: 20 MB.
Do you have drugs still renewable at another pharmacy?
- Yes
- No
Do you accept that we transfer your prescriptions to our pharmacy?
- Yes
- No
What is the name of your old pharmacy?
Name
This field is for validation purposes and should be left unchanged.