First Name*

Last Name*

Phone Number*

Date of Birth (i.e. Jan. 1, 2022)*

Would you like us to transfer all of your prescriptions:* Would you like us to transfer all of your prescriptions:* Yes No (please indicate below)

Which prescriptions would you like us to transfer (please type the name of the products)?*

Name of Current Pharmacy*

Phone Number of Current Pharmacy

Address (or Nearest Intersection) of Current Pharmacy*

Please choose an option:* Please choose an option:* Pick-up Delivery

Preferred contact method:* Preferred contact method:* Phone Email

Email Address*

Is there anything else you would like us to know?

I agree to the Victoria Wellness & Pharmacy Terms / Conditions:* I agree to the Victoria Wellness & Pharmacy Terms / Conditions:* I agree for Victoria Wellness & Pharmacy (130 Victoria St. S, Kitchener, ON N2G 2B5) to transfer the prescription(s) above per the Ontario’s Drug and Pharmacies Regulation Act (DPRA), Food and Drug Regulations, Narcotic Control Regulations and Benzodiazepines and Other Targeted Substances regulations and guidelines Regulation act. Click to learn more