Customer Registration Information To register IBR-ADV Pharmacy Program, fill in the form below. Items listed in bold must not be left blank. All information will be kept strictly confidential. Personal Information: Shopper's Login ID:   The name for login online to track orders. Password   4 to 10 characters or numbers. Verify Password   'IBR123' by default. Title Mr Mrs Ms Dr Last Name First Name Middle Name Birth date DD/MM/YYYY Gender Select One        Male Female Group Name IBR Contact Information: Address (line 1) Address (line 2) City Province British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Saskatchewan Yukon Territory Postcode 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 Daytime      Evening Insurance Information: If you are covered by a medical insurance plan in Canada, we will submit a claim on your behalf and charge you only your deductible when filling your prescription. Please provide your plan information below. If you do not have insurance, you may skip past it.   Insurance Company Select One ASSURE (SUNLIFE) BLUE CROSS/VETS DPC-The National Benefit Autho ESI CANADA GREEN SHIELD MANULIFE ODB - ONTARIO DRUG BENEFIT RX PLUS WORKERS COMPENSATION (WCIB) Select one: Primary Card Holder Spouse Dependent Dependent under 18 Member ID Number Group Number Doctor Information: Doctor's Last Name Doctor's 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 Select one: Doctor phone/fax your prescription Pharmacy calls your doctor 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 Prescription Refill Options: Refill Options: Refill Reminder by Phone Refill Reminder by Email No Refill You are now ready to submit this registration to ADV-CARE for approval. To submit this registration, click the Submit button. By submitting this patient personal profile, you make sure the patient has signed the registration Form and the Disclaimer and you certify that this information is correct.