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Sign up to become a Northwood Medical patient:
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Choose your RefillMeds.ca account credentials:
Username:
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E-mail:
*
Password:
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Confirm Password:
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Patient Information
Information about patient requesting prescription transfer:
Full Name:
*
Date of Birth:
*
Gender:
*
Male
Female
Prefer not to say
Street Address:
*
City:
*
Province:
*
Alberta
British Columbia
Manitoba
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Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon
Postal Code:
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Phone Number:
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Health Card Number:
*
Pharmacy(s) used in the last 12 months (please separate with a comma):
*
Please provide any Additional important information regarding your medication needs:
Important Note
RefillMeds.ca/Northwood Medical Services is committed to protecting the privacy of our customers' information. Any and all information provided on this form will be kept strictly confidential.
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