Consent and Authorization - MyEasyDose | Pharmacy | Multi-Dose Medication Packs Delivered by Mail
467
page-template-default,page,page-id-467,qode-quick-links-1.0,ajax_fade,page_not_loaded,,qode-title-hidden,qode_grid_1300,qode-theme-ver-17.2,qode-theme-bridge,qode_header_in_grid,wpb-js-composer js-comp-ver-5.5.5,vc_responsive

Consent and Authorization for Community Care Pharmacy Inc. O/A MyEasyDose.ca

 

For a downloadable version of our consent form please click here: Consent Form

 

Please do not fill out this form if you have not spoken to our pharmacy team. To book an appointment to discuss your medications please call 1-855-962-5198 from 9 am – 5 pm Monday – Friday or book an appointment here Thank You!

Patient Info


Parent/Guardian information if the patient is under 16 years of age (Leave blank if over 16 years of age)