Name

Address

Email

Phone

Date of Birth (YYYY/MMM/DD)

OHIP# (10 Digits + 2 Letter VC)

Are you an existing patient of ProHealth Boniface Park Pharmacy?

Yes
No
Not Sure

Type of Pharmacist Appointment

MedsCheck Medication Review
Pharmacist Consult at Pharmacy
Pharmacist Consult by Phone

Preferred Date, Time, and Reasons for the Pharmacist Appointment