Drug request

You can now submit your prescription request at
FOR YOUR KNOWN CHRONIC CONDITIONS using this form.

Please specify the name of the medication, the dosage,
the form, and the type of package if necessary.

Your prescription will be ready within 72 hours of your request
on your ID card. All you have to do is go to
with it to your pharmacy.

Name

First name

Phone number

Date of birth

E-mail address

Choice of doctor:

Take your pick:

Drug names, dosages and number of tablets for each drug.