Med Repeat Questionnaire

DISCUSSION FORUM

• RENEW MEDS HERE
• Test ordering -find the test you need download

Med Repeat Questionnaire

Med Renewal Request Form

2.*Phone Number? by providing the contact number you provide permission to contact you about the status of your medication renewal

3.*Your OHIP number? This will allow us to find you more easily in our database- it is not used for billing purpose. If you do not have OHIP state nil.

4.What medications are you currently on?

5.*Do you have any medication allergies? If so please list.

6.*Which medication do you need? Please list name and dosage required.

7.*What is your pharmacy? Please provide their phone number and fax number- should be on the container.

8.*Please acknowledge you are a registered patient with the doctor you are contacting for a renewal.

9.You agree to the following terms I am requesting 3 medications and these do not include controlled substances, hypnotics, antianxiety medication or antidepressants. I will not hold TMMI or my doctor liable for any delay in receiving treatment in a timely manner. I accept I will be charged $25 for online ordering and $35 for phone in reordering. I will carefully ascertain what I requested match on receipt what I am receiving and clarification will take place at this time. Neither TMMI or my doctor is responsible for any miscommunication of my prescription request. I accept it is my responsibility to carefully check what I have received. I am aware that I am not to reorder medication in cases of planning to be pregnant or being pregnant and agree to attend for urgent medical intervention if my condition is of an urgent nature. I am using this service to expedite my routine medications delivery or to provide medication for a condition I can easily recognize and it has not presented in any pattern different from before. I acknowledge if I am on blood thinners to add that to my list of medications in the above field and if my blood thinning is not in control not to proceed with this order.

10.Do you have an interest in any other services? If so please list ones of interest.

Referral initiation
MassagePhysioChiro referral
Receipt of test results
Reminders of appointments



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