Coburg Drug Mart RX PharmaChoice

What would you like to do? *

New Medication Existing Medication Refill Both New Medication and Existing Refill My prescription is with another pharmacy

What is your current pharmacy's name and address? *

Are you a new or existing patient? *

New Patient Existing Patient

Delivery or pickup in store? *

Delivery Pickup

What is your delivery address? *

Street and unit City Province or territory Postal code

Upload your prescription *

JPEG or PNG. Up to 3 files, 5 MB each and 10 MB total.

Choose images

RX number(s) for refill *

RX number 1

Date of birth *

Please describe relevant allergies (optional)

Health card number (optional)

Benefits or insurance information (optional)

What is your home address? *

Street and unit City Province or territory Postal code

Full patient name *

First name Last name

Patient email *

Phone number (optional)

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