JC Pharmacy

Submit a Prescription Transfer

Pharmacy Name

Pharmacy Phone Number

First Name

Last Name

Date of Birth

Address

City

Province

Postal Code

Email Address (optional)

Confirm Email (optional)

Personal Health Number (optional)

Phone Number

List any allergies you have (leave blank if none)

Send my prescription(s) to the:

Douglas Location

Gorge Location

Third Party Insurance Card (if you have one) Take Photo or Upload Image

Comments (instructions, urgency, etc):