Enrolment Form

We collect and use personal and health information as required by provincial and federal regulations to provide you with the highest possible pharmacy services. Your information is protected by the Personal Information Privacy Act (BC) and other provincial and federal laws.

IF you have questions about the collection and use of your information or any questions about this form CALL 604.870.0171 and speak with an Apex Pharmacy pharmacsit

Admission Date

CLIENT (PATIENT) PERSONAL INFORMATION

Full Legal Name

Birthday

Year

Month

Day

Personal Health Number (Care Card Number)

Phone

Cell

Facility Name

Room Number

Family Doctor

Doctor Phone

Previous Pharmacy

Pharmacy Phone

Allergies (list type of reation of known)

Medical Conditions/Diagnosis/Special Diet/Other Concerns

CONSENT TO SHARE INFORMATION

Provincial and federal laws allow sharing of information with other healthcare professionals directly involved in your care. You may elect to have information shared with others, such as family or friends, who assist you with your care and the law may allow information to be provided to surrogate adecision maker if you are unable to make decisions for yourself.

I choose to allow my personal and health onformation to be shared with the following individuals

Name/Realtionship/Phone

MEDICAL COVERAGE/INSURANCE INFORMATION

PharmaCare is the primary source of medication coverage for seniors in British Columbia, but you may have other plans such as Veterans Affairs and Insurance Plans/Group Benefits Plans.

Veterans Affairs K#

Please Upload Third Party Insurance Documents

BILLING INFORMATION

If invoices should be sent to someone other than the client, please complete this section.

Name

Relationship

Multi-line address

Country/Region

Address

City

Zip / Postal code

Do you have Power of Attorney?

Yes

If Yes, please provide copy

AUTHORIZATIONS FOR CHARGES

Multi choice

I authorize Apex Pharmacy Ltd to invoice me for ALL prescription or medication or supply charges of ANY AMOUNT not covered by my plan(s) without my prior approval.

I authorize Apex Pharmacy Ltd to invoice me for ALL prescription or medication or supply charges of UP TO an estimated $20 weekly per medication not covered by my plans(s) without my prior approval.

Call me to approve ALL charges. I understand that this may lead to delays in treatment.

Name

Signature

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Date

Year

Month

Day