Customer Registration Information To register LOC-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    Title Mr Mrs Ms Dr Last Name First Name Middle Name Birth date DD/MM/YYYY Gender Select One        Male Female Group Name LOC 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 Quebec 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 If you have prescription/s filled with another pharmacy in Ontario, please complete the pharmacy information below, or if you do not wish to have this information on file, you may skip past it. Pharmacy Information:   Pharmacy Name Pharmacy Phone only digits, no space. eg.4164446666 Pharmacy Fax only digits, no space. eg.4164446666 Pharmacy E-mail 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 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. 5. I also authorize and consent to ADV-CARE Pharmacy Inc.: (i) collecting and checking the accuracy of the personal and the personal health information I have provided and will be providing in the future; (ii) disclosing the information to third parties so that such third parties may provide verification of such personal information to them from information they have previously collected about me; (iii) using the information to fill my prescriptions and to collect payment (iv) disclosing the information to other pharmacies to whom my prescriptions may be transferred or who may assist them in filling my prescriptions; and (v) keeping my information on their premises or the premises of pharmacies to whom my prescriptions are transferred or who are assisting them; (vi) transfer any of my prescriptions to my local pharmacy or a pharmacy of their choice,(vii) recieve electronc communications from ADV-Care Pharmacy by phone, e-mail, SMS, fax or any communication means or (viii) retain another pharmacy to assist them to centrally fill my prescriptions. I acknowledge that ADV-CARE Pharmacy´s collection and use of my information is subject to their privacy policy which is available at www.adv-care.com/about.htm or which can be obtained by calling this number 1-888-471-4721.I also consent to recieve electronc communications from ADV-Care Pharmacy by phone, e-mail, SMS, fax or any communication means. By submitting this personal profile, to complete the registration process please sign the registration Form and certify that this information is correct.