New Registration

To register as a new shopper, fill in the form below. Items listed in bold must not be left blank. All information will be kept strictly confidential. We will not communicate this information to others as part of a mailing list.

Personal Information:
 
Shopper's Login ID:   The name you wish to use.
Password   4 to 10 characters or numbers.
Verify Password   Match exactly.
Challenge Question   Reset password question.
Challenge Answer   Reset password answer.
Title
Last Name
First Name
Middle Name
Birth date DD/MM/YYYY
Gender
Contact Information:
 
Address (line 1)
Address (line 2)
City
State
Zip
Daytime Phone Number only digits, no space. eg.4164446666
Evening Phone Number only digits, no space. eg.4164446666
Fax Number only digits, no space. eg.4164446666
E-mail
Best Time to Call
When filling a prescription, and/or purchasing over the counter (OTC) products, your medical information will be used to help us keep you free from drug interactions and inadvertent duplication or conflict. In such situations we will advise you and/or, with your permission, our pharmacist will consult with your doctor if needed.
Medical Information:
 
Allergies/Drug Intolerance:
Medical Conditions:
Pregnancy
Asthma
Cholesterol
Diabetes
 Bleeding Disorder
Glaucoma
Heart Condition
Hypertension
Please specify below other medical conditions not listed above:
Comments/Current medications (including herbal remedies):
Please consult the Questionnaire before entering your comments
Doctor Information:
 
For each Doctor that you are currently under the care of, please record their information on a separate Customs Statement.
 
Primary Doctor Last Name
Primary Doctor First Name
Doctor's Phone Number only digits, no space. eg.4164446666
Doctor's Fax Number only digits, no space. eg.4164446666
Doctor's E-mail
Doctor's Address
Doctor's City
Doctor's State/Prov.
Doctor's Zip.
Select one: Doctor phone/fax your prescription
      (print our information)
Pharmacy calls your doctor
Prescription Refill Options:
 
Refill Options: No Refill
Automatic Refill
Refill Reminder by Phone
Refill Reminder by Email
Shopper Demographics:

To help us better understand your needs, please fill out the following optional demographic information. If you do not want to volunteer any demographic information, move to the bottom of this form and click the Submit button.
 
Marital Status
Number of Household Members
Annual Household Income
 


You are now ready to submit your registration for approval. To submit your registration, click the Submit button.

Prior to submitting my personal profile, I acknowledge that I have read the following Limitation of Liability and Disclaimer and agree that:

1. The information available through this site is intended to assist in selecting non-prescription products and does not suggest diagnosis or treatment. This information is not a substitute for medical advice, treatment or attention.

2. I understand that neither ADV-Care Pharmacy nor this website has made any representations or warranties whatsoever. Without limiting the generality of the foregoing, neither ADV-Care Pharmacy nor this website has provided any representations or warranties of merchantability, fitness for a particular purpose or diagnosis. Further, neither ADV-Care Pharmacy nor this website represent or warrant that the information accessible on this website is accurate, complete or current.

3. Price and availability information is subject to change without notice.

4. Except as specifically stated on this site, neither ADV-Care Pharmacy nor any of its officers, directors, employees, agents or representatives will be liable for any damages of any kind arising out of, or in connection with, the use of this website. Without limiting the generality of the foregoing, there shall be no liability for damages of any kind including compensatory, direct, indirect or consequential damages for personal injury of any kind or for any reasons, including for loss of data, income or profit, loss of or damage to property and claims of third parties.

The use of this website and all agreements relating thereto are governed by the laws of the Province of Ontario. Any actions commenced with respect to this website or ADV-Care Pharmacy shall be adjudicated in the Province of Ontario. All users agree to attorn to Ontario for these purposes.

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