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.
Last Name
First Name
Middle Name
Birth date DD/MM/YYYY
Group Name IBR

Contact Information:
Address (line 1)
Address (line 2)
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
Best Time to Call

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: Primary Card Holder
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:
Bleeding Disorder
Heart Condition
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.